LETTERS TO THE EDITOR Percutaneous placement of a biliary self-expandable metallic stent for severe post-ERCP bleeding To the Editor: It is with great interest that we read the article by Valats et al1 on the successful management of post-ERCP bleeding with the use of covered self-expandable biliary stents, and we would like to take this opportunity to share our experience with a modified approach in a patient with severe bleeding after ERCP. Recently, a 52-year-old man was referred to our clinic for further evaluation of obstructive jaundice and weight loss. US examination of the abdomen revealed a 3 3 cm mass in the hilus of the liver; the margins could not be distinguished from the gallbladder. On subsequent ERCP, deep cannulation of the common bile duct (CBD) was achieved after a precut sphincterotomy, and the cholangiographic images revealed a stricture in the mid-CBD with dilatation of the proximal biliary tree, which prompted placement of a 10F 10-cm plastic biliary stent. Although the ERCP procedure was otherwise uneventful, the patient experienced melena 12 hours later and required 10 units of packed erythrocytes within 36 hours to maintain a hemoglobin concentration of more than 10 g/dL. Two attempts at hemostasis with use of a duodenoscope failed because the source of the bleeding could not be accurately located, owing to the massive bleeding and to large coagulum covering the duodenal lumen completely. However, endoscopic evidence was highly suggestive of either sphincterotomy bleeding or hemobilia from the identified tumor. The patient was consequently referred for percutaneous transhepatic cholangiography, during which a 10 mm
80 mm covered self-expandable metallic stent (SEMS) (Wallflex; Boston Scientific, MA) was placed next to the plastic stent, with its distal end slightly protruding into the duodenum through the ampulla of Vater. An external-internal drainage catheter was also placed before conclusion of the procedure (Fig. 1A). This was followed by conventional angiographic evaluation, which confirmed that bleeding was brought under control with no apparent extravasation of injected contrast dye (Fig. 1B). No other bleeding episode was observed during 3 weeks of followup. Although successful control of post-ERCP bleeding with endoscopic SEMS placement has been previously reported in the form of case series,2,3 Valats et al1 underlined the efficacy of this method in controlling hemobilia where the CBD rather than the sphincterotomy was the source of bleeding. Our case demonstrates that percutaneous placement of a SEMS is a viable alternative to the endoscopic approach for the management of bleeding from the CBD or postsphincterotomy bleeding, especially in cases in which endoscopic hemostasisis unachievable because of excessive hemorrhage or inaccessibility to the source of bleeding when conventional hemostatic techniques are used. Bulent Odemis, MD Department of Gastroenterology Yuksek Ihtisas Training and Research Hospital Ankara, Turkey Ali Shorbagi, MD Gastroenterology Division Department of Internal Medicine Near East University Hospital Lefkos¸a, Turkish Republic of Northern Cyprus
Figure 1. A, Fluoroscopic image obtained during percutaneous transhepatic cholangiography, showing dilated duodenum filled with coagulum. The plastic stent, metallic stent, and external-internal drainage catheter are also visible. B, Conventional angiographic image confirming successful hemostasis after placement of self-expandable metallic stent, with no extravasation of injected contrast dye around the papilla.
www.giejournal.org
Volume 80, No. 1 : 2014 GASTROINTESTINAL ENDOSCOPY 187
Letter to the editor
Mehmet Yurdakul, MD Department of Radiology Yuksek Ihtisas Training and Research Hospital Ankara, Turkey Serkan Torun, MD Erkin Oztas, MD Ertugrul Kayacetin, MD Department of Gastroenterology Yuksek Ihtisas Training and Research Hospital Ankara, Turkey
REFERENCES 1. Valats JC, Funakoshi N, Bauret P, et al. Covered self-expandable biliary stents for the treatment of bleeding after ERCP. Gastrointest Endosc 2013;78:183-7. 2. Shah JN, Marson F, Binmoeller KF. Temporary self-expandable metal stent placement for treatment of postsphincterotomy bleeding. Gastrointest Endosc 2010;72:1274-8. 3. Itoi T, Yasuda I, Doi S, et al. Endoscopic hemostasis using covered metallic stent placement for uncontrolled postendoscopic sphincterotomy bleeding. Endoscopy 2011;43:369-72.
ings suggest that H pylori infection may be involved in the colorectal mucosadCRAdCRC sequence.6,7 In a systematic review, we also reported an association between H pylori infection and insulin resistance, the major underlying mechanism responsible for the metabolic syndrome.8 Our data further indicate that H pylori infection might represent a further hit contributing to the pathogenesis of nonalcoholic fatty liver disease, representing the hepatic component of metabolic syndrome9; nonalcoholic fatty liver disease closely related to insulin resistance is involved in colon oncogenesis. Finally, studies from Taiwan suggest that H pylori infection with concomitant metabolic syndrome might further increase the risk of CRA.10 Viewing the aforementioned data, we consider that H pylori and metabolic syndrome–related colon oncogenesis might justify the earlier use of CRC screening programs mentioned by the authors and for other high-risk patients.1 Iordanis Romiopoulos, MD Jannis Kountouras, MD, PhD Stergios A. Polyzos, MD, PhD Christos Zavos, MD, PhD Nikolaos Kapetanakis, MD, PhD Georgia Deretzi, MD, PhD Elizabeth Vardaka, PhD Constantinos Kountouras, PhD Elena Tsiaousi, MD Kyriaki Anastasiadou, MD Nikolaos Giorgakis, MD Panagiota Boura, MD, PhD Panagiotis Katsinelos, MD, PhD Department of Medicine Second Medical Clinic Aristotle University of Thessaloniki Ippokration Hospital Thessaloniki, Macedonia, Greece
http://dx.doi.org/10.1016/j.gie.2013.12.001
Helicobacter pylori-related metabolic syndrome might justify earlier colorectal cancer screening To the Editor: Chang et al1 concluded that metabolic syndrome and smoking have a significant impact on the prevalence of advanced colorectal neoplasms and the diagnostic yields of screening tests in men aged 40 to 49 years, thereby justifying earlier colorectal cancer (CRC) screening programs in men; any factor that influences the risk of advanced neoplasms should be thoroughly investigated. However, the authors did not consider the potential impact of other widespread environmental factors (ie, Helicobacter pylori) on metabolic syndrome–related colon oncogenesis. In this regard, cross-sectional studies have identified a high prevalence of H pylori infection (72.1%) in Taiwan2; the prevalence of H pylori infection is 88.7% in duodenal ulcer patients and 90.5% in gastroduodenal ulcer patients in Taiwan.3 Recent data also indicate a serologic association between H pylori infection and the risk of colorectal adenoma (CRA) and CRC.4,5 However, the serologic measurement of infection status is less than perfect.4 Based on histology, the criterion standard for current H pylori diagnosis, our data from 50 CRC patients, 25 CRA patients, and 10 control individuals showed a significantly higher presence of H pylori in the CRA (68%) and CRC (84%) groups than in the control group (30%)5,6; the presence of H pylori was documented by immunohistochemical stain. These find188 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 1 : 2014
REFERENCES 1. Chang LC, Wu MS, Tu CH, et al. Metabolic syndrome and smoking may justify earlier colorectal cancer screening in men. Gastrointest Endosc 2014;79:961-9. 2. Chen HL, Chen MJ, Shih SC, et al. The socioeconomic status, personal habits, and prevalence of Helicobacter pylori infection in inhabitants of Lanyu. J Formos Med Assoc 2014 Jan 3. http://dx.doi.org/10.1016/j. jfma.2013.11.013. [Epub ahead of print]. 3. Chen TS, Luo JC, Chang FY. Prevalence of Helicobacter pylori infection in duodenal ulcer and gastro-duodenal ulcer diseases in Taiwan. J Gastroenterol Hepatol 2010;25:919-22. 4. Zhang Y, Hoffmeister M, Weck MN, et al. Helicobacter pylori infection and colorectal cancer risk: evidence from a large population-based case-control study in Germany. Am J Epidemiol 2012;175:441-50. 5. Kapetanakis N, Kountouras J, Zavos C, et al. Re: Helicobacter pylori infection and colorectal cancer risk: evidence from a large population-based case-control study in Germany. Am J Epidemiol 2012;176:566-7.
www.giejournal.org
80 mm covered self-expandable metallic stent (SEMS) (Wallflex; Boston Scientific, MA) was placed next to the plastic stent, with its distal end slightly protruding into the duodenum through the ampulla of Vater. An external-internal drainage catheter was also placed before conclusion of the procedure (Fig. 1A). This was followed by conventional angiographic evaluation, which confirmed that bleeding was brought under control with no apparent extravasation of injected contrast dye (Fig. 1B). No other bleeding episode was observed during 3 weeks of followup. Although successful control of post-ERCP bleeding with endoscopic SEMS placement has been previously reported in the form of case series,2,3 Valats et al1 underlined the efficacy of this method in controlling hemobilia where the CBD rather than the sphincterotomy was the source of bleeding. Our case demonstrates that percutaneous placement of a SEMS is a viable alternative to the endoscopic approach for the management of bleeding from the CBD or postsphincterotomy bleeding, especially in cases in which endoscopic hemostasisis unachievable because of excessive hemorrhage or inaccessibility to the source of bleeding when conventional hemostatic techniques are used. Bulent Odemis, MD Department of Gastroenterology Yuksek Ihtisas Training and Research Hospital Ankara, Turkey Ali Shorbagi, MD Gastroenterology Division Department of Internal Medicine Near East University Hospital Lefkos¸a, Turkish Republic of Northern Cyprus
Figure 1. A, Fluoroscopic image obtained during percutaneous transhepatic cholangiography, showing dilated duodenum filled with coagulum. The plastic stent, metallic stent, and external-internal drainage catheter are also visible. B, Conventional angiographic image confirming successful hemostasis after placement of self-expandable metallic stent, with no extravasation of injected contrast dye around the papilla.
www.giejournal.org
Volume 80, No. 1 : 2014 GASTROINTESTINAL ENDOSCOPY 187
Letter to the editor
Mehmet Yurdakul, MD Department of Radiology Yuksek Ihtisas Training and Research Hospital Ankara, Turkey Serkan Torun, MD Erkin Oztas, MD Ertugrul Kayacetin, MD Department of Gastroenterology Yuksek Ihtisas Training and Research Hospital Ankara, Turkey
REFERENCES 1. Valats JC, Funakoshi N, Bauret P, et al. Covered self-expandable biliary stents for the treatment of bleeding after ERCP. Gastrointest Endosc 2013;78:183-7. 2. Shah JN, Marson F, Binmoeller KF. Temporary self-expandable metal stent placement for treatment of postsphincterotomy bleeding. Gastrointest Endosc 2010;72:1274-8. 3. Itoi T, Yasuda I, Doi S, et al. Endoscopic hemostasis using covered metallic stent placement for uncontrolled postendoscopic sphincterotomy bleeding. Endoscopy 2011;43:369-72.
ings suggest that H pylori infection may be involved in the colorectal mucosadCRAdCRC sequence.6,7 In a systematic review, we also reported an association between H pylori infection and insulin resistance, the major underlying mechanism responsible for the metabolic syndrome.8 Our data further indicate that H pylori infection might represent a further hit contributing to the pathogenesis of nonalcoholic fatty liver disease, representing the hepatic component of metabolic syndrome9; nonalcoholic fatty liver disease closely related to insulin resistance is involved in colon oncogenesis. Finally, studies from Taiwan suggest that H pylori infection with concomitant metabolic syndrome might further increase the risk of CRA.10 Viewing the aforementioned data, we consider that H pylori and metabolic syndrome–related colon oncogenesis might justify the earlier use of CRC screening programs mentioned by the authors and for other high-risk patients.1 Iordanis Romiopoulos, MD Jannis Kountouras, MD, PhD Stergios A. Polyzos, MD, PhD Christos Zavos, MD, PhD Nikolaos Kapetanakis, MD, PhD Georgia Deretzi, MD, PhD Elizabeth Vardaka, PhD Constantinos Kountouras, PhD Elena Tsiaousi, MD Kyriaki Anastasiadou, MD Nikolaos Giorgakis, MD Panagiota Boura, MD, PhD Panagiotis Katsinelos, MD, PhD Department of Medicine Second Medical Clinic Aristotle University of Thessaloniki Ippokration Hospital Thessaloniki, Macedonia, Greece
http://dx.doi.org/10.1016/j.gie.2013.12.001
Helicobacter pylori-related metabolic syndrome might justify earlier colorectal cancer screening To the Editor: Chang et al1 concluded that metabolic syndrome and smoking have a significant impact on the prevalence of advanced colorectal neoplasms and the diagnostic yields of screening tests in men aged 40 to 49 years, thereby justifying earlier colorectal cancer (CRC) screening programs in men; any factor that influences the risk of advanced neoplasms should be thoroughly investigated. However, the authors did not consider the potential impact of other widespread environmental factors (ie, Helicobacter pylori) on metabolic syndrome–related colon oncogenesis. In this regard, cross-sectional studies have identified a high prevalence of H pylori infection (72.1%) in Taiwan2; the prevalence of H pylori infection is 88.7% in duodenal ulcer patients and 90.5% in gastroduodenal ulcer patients in Taiwan.3 Recent data also indicate a serologic association between H pylori infection and the risk of colorectal adenoma (CRA) and CRC.4,5 However, the serologic measurement of infection status is less than perfect.4 Based on histology, the criterion standard for current H pylori diagnosis, our data from 50 CRC patients, 25 CRA patients, and 10 control individuals showed a significantly higher presence of H pylori in the CRA (68%) and CRC (84%) groups than in the control group (30%)5,6; the presence of H pylori was documented by immunohistochemical stain. These find188 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 1 : 2014
REFERENCES 1. Chang LC, Wu MS, Tu CH, et al. Metabolic syndrome and smoking may justify earlier colorectal cancer screening in men. Gastrointest Endosc 2014;79:961-9. 2. Chen HL, Chen MJ, Shih SC, et al. The socioeconomic status, personal habits, and prevalence of Helicobacter pylori infection in inhabitants of Lanyu. J Formos Med Assoc 2014 Jan 3. http://dx.doi.org/10.1016/j. jfma.2013.11.013. [Epub ahead of print]. 3. Chen TS, Luo JC, Chang FY. Prevalence of Helicobacter pylori infection in duodenal ulcer and gastro-duodenal ulcer diseases in Taiwan. J Gastroenterol Hepatol 2010;25:919-22. 4. Zhang Y, Hoffmeister M, Weck MN, et al. Helicobacter pylori infection and colorectal cancer risk: evidence from a large population-based case-control study in Germany. Am J Epidemiol 2012;175:441-50. 5. Kapetanakis N, Kountouras J, Zavos C, et al. Re: Helicobacter pylori infection and colorectal cancer risk: evidence from a large population-based case-control study in Germany. Am J Epidemiol 2012;176:566-7.
www.giejournal.org
