Letters to the editor
Bang et al also raise the issue with the suggestion to use the “slow-pull or capillary” technique when performing EUS-FNB and cite a lack of adequate evidence. We acknowledge the paucity of data and clearly have stated in the article that the “capillary technique” is preferred with a moderate quality of evidence and a weak strength of recommendation. We acknowledge the pitfalls of using a “bottom line” statement, as pointed out by Dr Draganov and the recommendations not reflecting the complexity of the issue at hand. Although the GRADE methodology is used in formal guidelines, it has been described in systematic reviews and technical reviews. It is important to note that a technical review provides an informed appraisal of the existing literature with corresponding recommendations, which should be used to guide patient care and provide a framework for future research in this field. The purpose of this review using the outlined GRADE methodology is not to establish rigid standard of care measures, which remove individualized clinical decision making, but to guide endosonographers by using the best available evidence to select and individualize tissue acquisition techniques to optimize results. We thank Bang et al and Dr Draganov for their comments, but reiterate to the readership that the conclusions of this technical review were based on established and accepted methodologies used across medicine and have been adopted by many national and international societies.
DISCLOSURE Dr Muthusamy is a speaker for Covidien GI solutions and a consultant for Boston Scientific. Dr Komanduri is a consultant for Boston Scientific and Cook Medical and a speaker for Covidien GI solutions. All other authors disclosed no financial relationships relevant to this article.
REFERENCES 1. Wani S, Muthusamy VR, Komanduri S. EUS-guided tissue acquisition: an evidence-based approach (with videos). Gastrointest Endosc 2014;80: 939-59.e7. 2. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6. 3. Egger M, Smith GD, Altman D. Systematic reviews in health care – metaanalysis in context. BMJ 2005. http://dx.doi.org/10.1016/j.gie.2015.02.014
An unusual foreign body in the ileum To the Editor: An ingested foreign body generally passes into the GI tract successfully after several days to several weeks. However, it may not pass many potential sites of physiologic anatomic narrowing, including the esophageal sphincters, pylorus, and ileocecal valve.1 We report a fixed dental prosthesis that was impacted at the ileum, causing abdominal pain and mimicking appendicitis. A 50-year-old woman was admitted with right lower quadrant abdominal pain. One week prior, while eating dinner, her fixed dental prosthesis had dislodged from her lower right jaw and was swallowed accidentally. In the emergency department, the prosthesis was found by abdominal radiograph to be in the stomach. Endoscopy was delayed because she had recently ingested a full meal, and she was observed with close follow-up for 7 days. On the seventh day she began to have abdominal pain in the right lower quadrant. She did not have nausea, vomiting, melena, or hematochezia. She had abdominal tenderness at deep palpation. Laboratory tests showed normal results. A plain abdominal radiograph showed the fixed dental prosthesis in the right lower quadrant of her
ACKNOWLEDGMENT We gratefully acknowledge the efforts of Lindsay Hosford, BA. Srinadh Komanduri, MD Division of Gastroenterology and Hepatology Northwestern University Chicago, Illinois, USA Sachin Wani, MD Division of Gastroenterology and Hepatology University of Colorado Anschutz Medical Campus Aurora, Colorado, USA V. Raman Muthusamy, MD Division of Digestive Diseases University of California Los Angeles Los Angeles, California, USA
Figure 1. Plain abdominal radiographic appearance of fixed dental prosthesis.
1302 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
Letters to the editor
Foreign bodies bigger than 2.5 cm or longer than 5 cm may not pass the pylorus or ileocecal valve.1 Radiographic evaluation is essential for differential diagnosis of the location, nature, and size of the body. The majority of foreign bodies pass the GI tract without symptoms unless an adverse event (eg, obstruction or perforation) occurs. Hence, most cases do not require treatment. If the object does not pass spontaneously in a timely manner, it is removed by endoscopy or surgery.1,2 Omer Ozturk, MD Seyfettin Koklu, MD Department of Gastroenterology Hacettepe University School of Medicine Ankara, Turkey Figure 2. Colonoscopic appearance of fixed dental prosthesis impacted at the ileocecal valve.
abdomen (Fig. 1). Colonoscopy was performed, and a dental prosthesis was seen impacted at the ileocecal valve (Fig. 2). The prosthesis was removed successfully by use of a basket. She was free of symptoms at the followup visit.
REFERENCES 1. De Souza JG, Schuldt Filho G, Pereira Neto AR, et al. Accident in implant dentistry: involuntary screwdriver ingestion during surgical procedure. A clinical report. J Prosthodont 2012;21:191-3. 2. Ayantunde AA, Oke T. A review of gastrointestinal foreign bodies. Int J Clin Pract 2006;60:735-9. http://dx.doi.org/10.1016/j.gie.2014.12.060
ERRATUM In the article “A randomized, controlled trial comparing real-time insertion pain during colonoscopy confirmed water exchange to be superior to water immersion in enhancing patient comfort” (Gastrointest Endosc 2015;81:557-66), there was an error in Figure 1. The corrected figure appears below:
www.giejournal.org
Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1303
Bang et al also raise the issue with the suggestion to use the “slow-pull or capillary” technique when performing EUS-FNB and cite a lack of adequate evidence. We acknowledge the paucity of data and clearly have stated in the article that the “capillary technique” is preferred with a moderate quality of evidence and a weak strength of recommendation. We acknowledge the pitfalls of using a “bottom line” statement, as pointed out by Dr Draganov and the recommendations not reflecting the complexity of the issue at hand. Although the GRADE methodology is used in formal guidelines, it has been described in systematic reviews and technical reviews. It is important to note that a technical review provides an informed appraisal of the existing literature with corresponding recommendations, which should be used to guide patient care and provide a framework for future research in this field. The purpose of this review using the outlined GRADE methodology is not to establish rigid standard of care measures, which remove individualized clinical decision making, but to guide endosonographers by using the best available evidence to select and individualize tissue acquisition techniques to optimize results. We thank Bang et al and Dr Draganov for their comments, but reiterate to the readership that the conclusions of this technical review were based on established and accepted methodologies used across medicine and have been adopted by many national and international societies.
DISCLOSURE Dr Muthusamy is a speaker for Covidien GI solutions and a consultant for Boston Scientific. Dr Komanduri is a consultant for Boston Scientific and Cook Medical and a speaker for Covidien GI solutions. All other authors disclosed no financial relationships relevant to this article.
REFERENCES 1. Wani S, Muthusamy VR, Komanduri S. EUS-guided tissue acquisition: an evidence-based approach (with videos). Gastrointest Endosc 2014;80: 939-59.e7. 2. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924-6. 3. Egger M, Smith GD, Altman D. Systematic reviews in health care – metaanalysis in context. BMJ 2005. http://dx.doi.org/10.1016/j.gie.2015.02.014
An unusual foreign body in the ileum To the Editor: An ingested foreign body generally passes into the GI tract successfully after several days to several weeks. However, it may not pass many potential sites of physiologic anatomic narrowing, including the esophageal sphincters, pylorus, and ileocecal valve.1 We report a fixed dental prosthesis that was impacted at the ileum, causing abdominal pain and mimicking appendicitis. A 50-year-old woman was admitted with right lower quadrant abdominal pain. One week prior, while eating dinner, her fixed dental prosthesis had dislodged from her lower right jaw and was swallowed accidentally. In the emergency department, the prosthesis was found by abdominal radiograph to be in the stomach. Endoscopy was delayed because she had recently ingested a full meal, and she was observed with close follow-up for 7 days. On the seventh day she began to have abdominal pain in the right lower quadrant. She did not have nausea, vomiting, melena, or hematochezia. She had abdominal tenderness at deep palpation. Laboratory tests showed normal results. A plain abdominal radiograph showed the fixed dental prosthesis in the right lower quadrant of her
ACKNOWLEDGMENT We gratefully acknowledge the efforts of Lindsay Hosford, BA. Srinadh Komanduri, MD Division of Gastroenterology and Hepatology Northwestern University Chicago, Illinois, USA Sachin Wani, MD Division of Gastroenterology and Hepatology University of Colorado Anschutz Medical Campus Aurora, Colorado, USA V. Raman Muthusamy, MD Division of Digestive Diseases University of California Los Angeles Los Angeles, California, USA
Figure 1. Plain abdominal radiographic appearance of fixed dental prosthesis.
1302 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5 : 2015
www.giejournal.org
Letters to the editor
Foreign bodies bigger than 2.5 cm or longer than 5 cm may not pass the pylorus or ileocecal valve.1 Radiographic evaluation is essential for differential diagnosis of the location, nature, and size of the body. The majority of foreign bodies pass the GI tract without symptoms unless an adverse event (eg, obstruction or perforation) occurs. Hence, most cases do not require treatment. If the object does not pass spontaneously in a timely manner, it is removed by endoscopy or surgery.1,2 Omer Ozturk, MD Seyfettin Koklu, MD Department of Gastroenterology Hacettepe University School of Medicine Ankara, Turkey Figure 2. Colonoscopic appearance of fixed dental prosthesis impacted at the ileocecal valve.
abdomen (Fig. 1). Colonoscopy was performed, and a dental prosthesis was seen impacted at the ileocecal valve (Fig. 2). The prosthesis was removed successfully by use of a basket. She was free of symptoms at the followup visit.
REFERENCES 1. De Souza JG, Schuldt Filho G, Pereira Neto AR, et al. Accident in implant dentistry: involuntary screwdriver ingestion during surgical procedure. A clinical report. J Prosthodont 2012;21:191-3. 2. Ayantunde AA, Oke T. A review of gastrointestinal foreign bodies. Int J Clin Pract 2006;60:735-9. http://dx.doi.org/10.1016/j.gie.2014.12.060
ERRATUM In the article “A randomized, controlled trial comparing real-time insertion pain during colonoscopy confirmed water exchange to be superior to water immersion in enhancing patient comfort” (Gastrointest Endosc 2015;81:557-66), there was an error in Figure 1. The corrected figure appears below:
www.giejournal.org
Volume 81, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 1303
