Paul Thomas Kröner

A 75-year-old man was admitted to our hospital because of worsening chronic hemolytic anemia and hematochezia. His medical history was significant for diabetes mellitus, coronary artery disease, and autoimmune hemolytic anemia (AIHA). Idiopathic AIHA was diagnosed 3 years prior to the current admission and was warm antibody-mediated, and direct antiglobulin test (Coombs test) positive. Initially he was placed on steroids, but due to recurrent hemolytic episodes, he was subsequently placed on different immunosuppressive agents, including azathioprine, cyclophosphamide, and mycophenolate mofetil. Esophagogastroduodenoscopy and colonoscopy were unremarkable. Capsule endoscopy showed an ulcerated tumor located in the ileum ([Fig. 1 a]). A retrograde deep enteroscopy confirmed a large tumor in the ileum ([Fig. 1 b]). The patient underwent surgical resection of the mass ([Fig. 1 c]). Histopathology revealed diffuse large B-cell lymphoma (DLBCL), an aggressive subtype of non-Hodgkin lymphoma (NHL) ([Fig. 1 d–f], [Video 1]). Video 1 Small-bowel B-cell lymphoma presenting as autoimmune hemolytic anemia and severe obscure gastrointestinal bleeding. The Coombs test was negative 2 months later, suggesting that the mass was the source of the autoantibodies. Combination R-CHOP therapy (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone) resulted in remission of the lymphoma. This case highlights the occurrence of two conditions leading to severe anemia. Whenever an AIHA is present, the clinician must be aware of lymphomas. Interestingly, AIHA may occur prior to NHL (from 3 months to 13 years before lymphoma diagnosis), concurrent with (6 months before until 6 months after NHL diagnosis), at relapse of NHL, or in complete remission after successful treatment of the NHL; however, the majority of cases occur concurrently [1] [2] [3]. The most common primary small intestine lymphoma is DLBCL (58 % of cases) and perforation is a frequent complication. Endoscopically, AIHA can be of polypoid type in 25 % of cases, ulcerative type in 54 %, multiple polyposis in 5 %, diffuse-infiltrating type in 6 %, and mixed type in 10 % of patients [2] [3]. Endoscopy_UCTN_Code_CCL_1AC_2AC Article published online: 11 July 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background Double balloon enteroscopy remains a resource and time-intensive procedure that is not available in many endoscopy units. Aims We aimed to identify variables impacting the speed and completion of double balloon enteroscopy. Methods We retrospectively reviewed 550 patients. Using a mean time and distance for both the antegrade and retrograde approach, we determined the procedure speed and assessed factors that influenced it. In addition, we assessed the factors that contributed to a complete double balloon enteroscopy. Results A total of 386 antegrade and 164 retrograde double balloon enteroscopies were performed. Greater than 10 AVMs requiring treatment was a negative predictor (AOR 0.25, CI 0.11–0.51, p < 0.001), whereas age greater than 60 years (AOR 2.66, CI 1.18–6.65, p = 0.025) was a positive predictor of a fast antegrade enteroscopy. For retrograde, prior abdominal surgery was the only factor that trended to significance (AOR 0.38, CI 0.14–0.99, p = 0.052). A total of 120 combined procedures were performed. Female gender (AOR 2.62, CI 1.16–6.24, p = 0.02), history of prior abdominal surgery (AOR 0.31, CI 0.13–0.70, p = 0.006) and Boston bowel pre-preparation score of greater than 6 (AOR 4.50, CI 1.59–14.30, p = 0.006) were the only significant predictors of a complete procedure. Conclusion By applying double balloon enteroscopy speed, a novel method of measuring procedure efficiency, we were able to more reliably identify the factors that will negatively impact the speed and success of the procedure.

Background/Aims: Endoscopic visualization of the microscopic anatomy can facilitate the real-time diagnosis of pancreatobiliary disorders and provide guidance for treatment. This study aimed to review the technique, image classification, and diagnostic performance of confocal laser endomicroscopy (CLE).Methods: We conducted a systematic review of CLE in pancreatic and biliary ducts of humans, and have provided a narrative of the technique, image classification, diagnostic performance, ongoing research, and limitations.Results: Probe-based CLE differentiates malignant from benign biliary strictures (sensitivity, ≥89%; specificity, ≥61%). Needlebased CLE differentiates mucinous from non-mucinous pancreatic cysts (sensitivity, 59%; specificity, ≥94%) and identifies dysplasia. Pancreatitis may develop in 2-7% of pancreatic cyst cases. Needle-based CLE has potential applications in adenocarcinoma, neuroendocrine tumors, and pancreatitis (chronic or autoimmune). Costs, catheter lifespan, endoscopist training, and interobserver variability are challenges for routine utilization.Conclusions: CLE reveals microscopic pancreatobiliary system anatomy with adequate specificity and sensitivity. Reducing costs and simplifying image interpretation will promote utilization by advanced endoscopists.

Background and study aims Splenic injury (SI) during colonoscopy is an underappreciated adverse event. Our aim was to examine the occurrence and outcomes of patients who developed SI after inpatient colonoscopy using a nationwide dataset. Patients and methods Retrospective, observational study using the National Inpatient Sample (NIS) between 2012 and 2018. All patients with ICD9/10CM procedural codes for colonoscopy with or without SI were included. The primary outcome was the association between SI and inpatient colonoscopy. Secondary outcomes were inpatient morbidity, mortality, resource utilization, splenectomy rates, hospital length of stay and total hospital costs and charges. Comparative analyses were performed between patients with and without SI. Multivariate regression analyses were utilized. Results A total of 2,258,040 of inpatient colonoscopies were included. Of these, 240 had associated SI and 25 patients required splenectomy (10.4 %). The incidence of colonoscopy-associated SI remained relatively stable between 2012 and 2018 (0.033 % versus 0.020 %, respectively). The mean age of patients with and without SI was 63.7 and 64.1 years, respectively. The occurrence of SI was calculated as 10.63 cases per 100,000 inpatient colonoscopies. Patients who had associated SI displayed significantly higher odds of inpatient mortality (aOR: 14.45) and ICU stay (aOR: 10.11) compared to those without SI. Conclusions Splenic injury confers significantly higher odds of inpatient mortality, and resource utilization. The incidence of SI related to colonoscopy remained stable during the study period. Although uncommon, SI should be considered when encountering patients with abdominal pain after colonoscopy.

Aim: The existing literature was updated, assessing the use of surgery in patients with ulcerative colitis in more recent years.Methods: This was a retrospective observational study identifying all patients with ulcerative colitis within the National Inpatient Sample, years 2009–2018. All patients with International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification diagnostic codes for ulcerative colitis were included. The primary outcome was the trend in total number of total abdominal colectomy, proctocolectomy and simultaneous versus delayed pouch construction.Results: A total of 1 184 711 ulcerative‐colitis‐related admissions were identified. An increase of 18.6% in the number of patients was observed, while the number of surgeries decreased. A total of 40 499 patients underwent total colectomy, annually decreasing from 5241 to 3185. The number of proctocolectomies without pouch decreased from 1191 to 530, while the number of patients undergoing pouch construction decreased from 2225 to 1284. The proportion of patients undergoing initial pouch at time of proctocolectomy decreased from 995 (45%) to 265 (21%), while the proportion of patients undergoing delayed pouch construction in 2018 was 79% (n = 1120).Conclusion: Surgery use in ulcerative colitis has decreased in the last decade despite increasing numbers of hospital admissions in patients with this condition. While the overall proportion of patients undergoing pouch construction remained stable, the majority of patients were initially treated with total colectomy and their ileal pouches werre constructed in a delayed fashion.