Randomised study of endoscopic biliary endoprosthesis versus duct clearance for bileduct stones in high-risk patients.

BACKGROUND: The value of an endoprosthesis for long-term management of bileduct stones has not been formally established. The main theoretical advantage of endoprosthesis insertion (BE) over conventional endoscopic duct clearance (DC) is the prevention of stone impaction, with obstruction and consequent cholangitis or pancreatitis. In a randomised study we compared the results of these two methods in patients with symptomatic bileduct stones who were at high risk because of old age (> 70 yr) or serious debilitating disease. METHODS: 43 high-risk patients were randomised to BE with a 7F double-pigtail endoprosthesis and < 0.75 cm sphincterotomy, and 43 to DC with standard 1.25-1.50 cm sphincterotomy and stone extraction by balloon or basket, with or without mechanical lithotripsy. The principal endpoint was the rate of biliary related complications. FINDINGS: In the BE group biliary drainage was achieved in the first session in all but one patient (who required 2 sessions). In the DC group, 24 patients had duct clearance at the first attempt and 35 (81%) after a median of 2 sessions (range 2-4); eight of this group had an endoprosthesis inserted to maintain long-term drainage. At 72 h the complication rates were 7% in the BE group and 16% in the DC group (p = 0.18). However, the long-term complication rate for BE was higher: by Kaplan-Meier analysis, at a median of 20 months the proportions free of biliary complications were 64% BE and 86% DC (p = 0.03, log-rank test). INTERPRETATION: For immediate bileduct drainage, endoprosthesis insertion proved a safe and effective alternative to duct clearance. Because of the risk of subsequent cholangitis, its use as a definitive treatment should be confined to highly selected cases.

Percutaneous endoscopic gastrostomy: evaluation of insertion by an endoscopy nurse practitioner.

OBJECTIVE: To evaluate the success rate and complications of percutaneous endoscopic gastrostomy (PEG) insertion performed with an endoscopy nurse practitioner, rather than a second doctor, carrying out percutaneous gastric puncture. DESIGN: A prospective evaluation of one nurse'e performance. SETTING: The endoscopy unit in a district general hospital. METHODS: An experienced endoscopy nurse, who had undergone a specific training course in PEG insertion, participated in PEG placement in 50 unselected patients over a one year period. The outcome and complications were compared with 50 PEGs inserted over the same period by medical personnel. A standard 'pull' technique was used to insert a 15Fr tube under sedation and local anaesthetic. RESULTS: The nurse was successful in PEG placement in all patients. Immediate complications from the procedure occurred in two cases in both the nurse-assisted and doctor-assisted groups. These were directly related to the gastric puncture in only one patient in each group; the others were respiratory complications related to the gastroscopy (resulting in the death of one patient). Thirty-day mortality was 8% in the nurse-assisted group and 12% following doctor-assisted PEG (mainly due to progression of the underlying condition). Outcome at 3 months was similar in the two groups, except for a slightly lower incidence of stomal infection in the nurse-assisted group. CONCLUSION: The participation of an endoscopy nurse practitioner in the gastric puncture for PEG insertion appeared to be safe and effective and offered advantages in terms of the efficient provision of a PEG placement service, increased continuity of care for the patients and an enhanced professional role for the nurse involved.

Duodenal mucosal ferritin in rheumatoid arthritis: implications for anaemia of chronic disease.

Anaemia is a common feature of rheumatoid arthritis (RA) and other chronic diseases. Among the alterations in iron metabolism contributing to this effect is a decrease in intestinal iron absorption. The mechanism for this is unknown, but might involve a 'mucosal block' process similar to that proposed in iron overload, whereby increased expression of an enterocyte storage protein binds absorbed iron and prevents its transfer to the circulation. We examined the effect of disease-modifying therapy on ferritin expression in duodenal mucosa in RA to determine whether it may play a role in the 'mucosal block' process. Endoscopic small bowel biopsies were obtained from 11 patients with active RA both before, and 6 months after, a course of either gold or methotrexate (MTX). Mucosal ferritin levels in small bowel and stomach were measured by radioimmune assay. Duodenal mucosal ferritin decreased significantly following treatment (p < 0.05). There were no changes in gastric mucosal ferritin. The fall in duodenal mucosal ferritin correlated with indices of disease activity at start of therapy, and the largest decreases were in those patients showing the best response to treatment in terms of a fall in inflammatory markers. Site-specific changes in mucosal ferritin may underlie the altered iron absorption observed in active inflammatory disease by modifying the enterocyte 'mucosal block'.

Acute phlegmonous gastritis.

A fatal case of acute phlegmonous gastritis in a 30 year old man is reported. It was caused by Group A Streptococcus (M type 1, T type 1). Although extremely rare, clinicians need to be aware of this condition as, without intervention, it is rapidly fatal. The recommended treatment is antibiotics combined with surgical resection.