Symptomatic gastroparesis in a patient with achalasia.

We present a case of a patient with achalasia who developed symptomatic gastroparesis after botulinum toxin injection therapy. Symptoms responded to prokinetics. Pathophysiology of gastric motility disturbances in patients with achalasia is discussed.

Management of inflammatory bowel disease.

Patients with an inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, have recurrent symptoms with considerable morbidity. Patient involvement and education are necessary components of effective management. Mild disease requires only symptomatic relief and dietary manipulation. Mild to moderate disease can be managed with 5-aminosalicylic acid compounds, including olsalazine and mesalamine. Mesalamine enemas and suppositories are useful in treating proctosigmoiditis. Antibiotics such as metronidazole may be required in patients with Crohn's disease. Corticosteroids are beneficial in patients with more severe symptoms, but side effects limit their use, particularly for chronic therapy. Immunosuppressant therapy may be considered in patients with refractory disease that is not amenable to surgery. Inflammatory bowel disease in pregnant women can be managed with 5-aminosalicylic acid compounds and corticosteroids. Since longstanding inflammatory bowel disease (especially ulcerative colitis) is associated with an increased risk of colon cancer, periodic colonoscopy is warranted.

Serum electrolyte abnormalities secondary to Fleet's Phospho-Soda colonoscopy prep. A review of three cases.

The authors report three cases of adverse reactions to commonly used lavage solutions generally believed harmless.

Localization of colonic lesions with endoscopic tattoo.

PURPOSE: Intraoperative localization of small tumors or polypectomy sites is frequently a difficult problem. In addition, the distance measured from the anus to the lesion by the endoscopist can be inaccurate. The purpose of our study was to evaluate the utility of India ink tattoo injection as a preoperative marking technique before colon surgery. METHODS: Colonic lesions were marked at preoperative colonoscopy, by multiple, small-volume injections of sterile India ink using a sclerotherapy needle, adjacent to the lesion. RESULTS: This technique was used in 14 patients with colonic carcinoma or villous adenoma not amenable to polypectomy. There was excellent intraoperative localization of the lesion in 11 patients. The complication rate was 7 percent. CONCLUSION: Colon tattoo allows precise localization of lesions with minimal risk at the time of resection.

A randomized study of a pH sensor feeding tube vs a standard feeding tube in patients requiring enteral nutrition.

Postpyloric feedings are a widely practiced form of enteral nutrition. We prospectively randomized two groups of hospital patients to receive a standard feeding tube or a feeding tube that uses a pH sensor to facilitate postpyloric placement and compared placement speed and accuracy, displacement detection, and costs for the two groups. Thirty-nine patients were randomized, with 20 receiving a pH sensor feeding tube and 19 an identical non-pH sensor feeding tube. An x-ray of the kidneys, ureter, and bladder was taken at 1, 6, and 48 hours after placement in both groups. Separate cost-benefit analyses were done by using retrospective chart review of costs for a separate 20-patient standard feeding tube group and calculated costs for a 20-patient hypothetical pH sensor group. At 1 hour, the duodenum was reached in 53% of the pH sensor feeding tube patients and 45% of the standard feeding tube patients (the difference was not significant). At 48 hours, 93% of the pH sensor feeding tubes reached the duodenum vs 67% of the standard feeding tubes (p < .08). Thirty percent of the pH sensor patients had an initial gastric pH > or = 4, negating pH sensor benefit in tube placement. In the remaining 70% of the patients, placement with the pH sensor had a 100% specificity compared with the x-ray of the kidneys, ureter, and bladder. Displacement was easily detected with routine pH monitoring in three of the pH sensor feeding tube patients and corrected. It was detected in two standard feeding tube patients, one of whom aspirated.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term outcome after endoscopic sphincterotomy in patients with biliary colic and suspected sphincter of Oddi dysfunction.

Seventy-three highly selected patients (35 type II, 38 type III) with intractable biliary-type pain were studied with biliary manometry after a baseline endoscopic retrograde cholangiopancreatography was normal or showed only duct dilatation. No differences between the two groups were noted in regard to baseline sphincter hypertension (60% versus 55%), improvement after endoscopic sphincterotomy at mean follow-up of 3 years, or post-procedure pancreatitis rates (15% versus 16%). Although not statistically significant, a tendency for patients with bile ducts > or = 12 mm to have sustained clinical improvement after sphincterotomy was noted in comparison with patients having ducts < 12 mm; an inverse correlation between improvement in symptoms and presence of an intact gallbladder at baseline was also seen. The authors suggest that the current classification, which divides patients with recurrent right upper quadrant pain into types I, II, and III, is inadequate to define either incidence of sphincter of Oddi dysfunction or subsequent response to endoscopic sphincterotomy.

New challenge for endorectal sonography: diagnosis of fecal incontinence.

The puborectalis muscle is a major determinant in the control of fecal continence. With endorectal sonography puborectalis function was assessed by determining puborectalis length in the resting (D1) and contracted (D2) states and calculating the percentage of shortening (D1-D2/D1)(100). The puborectalis length was defined as the shortest distance between the symphysis pubis and the rectal mucosa. The mean puborectalis length at rest did not differ in control subjects (29.5 +/- 1.0 mm) and incontinent patients (29.0 +/- 2.9 mm). With voluntary contraction a statistically significant difference (P < 0.001) was seen in the percentage of shortening between control subjects (15.4 +/- 1.1%) and incontinent patients (4.7 +/- 2.8%). Endorectal ultrasonography is a useful method to diagnose fecal incontinence.

Portal colopathy: prospective study of colonoscopy in patients with portal hypertension.

Twenty patients with portal hypertension related to a variety of causes prospectively underwent colonoscopy for hematochezia (n = 10), hemoccult positive stool and anemia (n = 9), or polyp found with screening flexible sigmoidoscopy (n = 2) (includes 1 patient with anemia/heme-positive stool). Twelve patients (60%) had previously undergone a course of sclerotherapy, and 10 (50%) had endoscopic evidence of congestive gastropathy. Colonoscopic findings included mucosal abnormalities resembling multiple vascular ectasias in 14 (70%), 4 of whom also had endoscopic features suggesting a mild, chronic colitis. Neither signs of chronic liver disease nor stigmata suggestive of more severe portal hypertension correlated with the colonoscopic findings. Two patients required heater probe therapy for actively oozing lesions resembling vascular ectasias and an additional two patients sclerotherapy for bleeding midrectal varices. Although likely an overestimate of the frequency, this study suggests that portal colopathy can occur in portal hypertension. Vascular ectasialike lesions in such settings may be associated with acute as well as chronic gastrointestinal bleeding and may require pharmacological, directed endoscopic, or portal decompressive therapy. Additional studies are required to determine not only the pathophysiology but also the true frequency of this entity.

Disposable endoscopic biopsy forceps: comparison with standard forceps of sample size and adequacy of specimen.

Disposable biopsy forceps have recently been introduced into the field of endoscopy. We have analyzed biopsy size and histologic interpretation of samples obtained with the disposable forceps and compared them to those obtained with reusable forceps. In the 18 patients studied, 49 samples were collected with the reusable forceps and 47 samples with the disposable. Biopsy sites included the colorectum in 50%, esophagus in 22%, small bowel in 17%, and stomach in 11% of the patients. We found that statistically smaller samples were collected by the disposable biopsy forceps than by the reusable (2.48 +/- 1.11 mm versus 1.99 +/- 0.55 mm, p = 0.006). The smaller biopsy size with disposable forceps was not clinically important since all but one of 47 specimens were interpreted as adequate for histologic diagnosis. The convenience, potential cost savings, and prevention of the spread of communicable agents afforded by disposable biopsy forceps make them a possible alternative to conventional forceps in some clinical settings.

Long-term follow-up in patients who have undergone balloon dilation for gastric outlet obstruction.

Although balloon dilation for gastric outlet obstruction has supplanted vagotomy plus drainage or resective therapy in some institutions, there are no long-term data which demonstrate what percentage of patients ultimately requires surgical intervention. Of 23 evaluable patients treated with hydrostatic balloon dilation in our institution, 70% were asymptomatic at a mean follow-up of 2.5 years. Five patients required surgery--one for acute perforation and the other four for symptoms of continued obstruction, despite one to three additional attempts at dilation. Only three of seven patients with previous gastric resection had a satisfactory long-term result. Whereas endoscopic therapy initially cost one tenth to one fifth that of surgical intervention, such figures do not factor for loss of productivity, on the one hand, or potential need for chronic H2 blockade, on the other. Despite instruction to the contrary, only 6 of 15 (40%) active patients continue acid-suppressive therapy. We conclude that balloon dilation remains a viable alternative for selected patients with gastric outlet obstruction.

Long-term survival in patients undergoing percutaneous endoscopic gastrostomy and jejunostomy.

Percutaneous endoscopic gastrostomy (PEG) used to supply enteral nutrition has supplanted surgically placed feeding tubes in many institutions. These tubes are currently placed in: 1) patients with reversible disease with potential for recovery (stroke, Guillain-Barré syndrome); 2) patients with incurable disease with potential for extended survival (head and neck cancer, amyotrophic lateral sclerosis); or 3) patients who are terminal or seriously debilitated (head trauma, systemic malignancies). Few data are currently available regarding long-term survival, survival difference between various patient populations, and incidence of recovery of oral intake with subsequent PEG tube removal. In this study, records of 191 patients in whom PEG tubes were placed were retrospectively reviewed and information collected regarding underlying diseases (malignant vs nonmalignant), survival, and incidence of subsequent tube removal. Of the patients, 68 (36%) had cancer, and 123 (64%) had benign disease (usually stroke or other neurologic disorder). Survival curve analysis demonstrated that one-third of patients were dead within 60 days of PEG placement, and half were dead in the first 6 months. Total deaths were 115 (60%) at a median time of 164 days. No mortality was directly related to acute or subsequent PEG tube complications. Feeding tubes were removed in 41 patients (21%), 10 with cancer (5%), and 31 without (16%, p less than 0.05). These data on limited patient survival and low incidence of recovery of oral intake suggest that facilitation of hospital discharge into a less expensive home care or step-down facility is the most likely goal to be realized after PEG placement. Further, these results raise questions regarding the appropriateness of PEG placement in patients with anticipated early mortality or low likelihood of hospital discharge.

Tube dysfunction following percutaneous endoscopic gastrostomy and jejunostomy.

Percutaneous endoscopic gastrostomy (PEG) and jejunostomy (PEJ) have supplanted their surgical counterparts in many institutions. Previous reports have claimed advantages in placing PEJ tubes because of reduced gastroesophageal reflux, prevention of aspiration, and improved tube anchoring distally. We reviewed the records of 191 patients who underwent placement of PEG/J tubes. Data collected included incidence of tube dysfunction, need for tube replacement or removal, and aspiration after PEG or PEJ tube placement. Tube dysfunction, defined as peritube leakage, plugging, fracture, or migration, occurred in 36% of patients over a mean follow-up period of 275 days and was significantly more common and likely to necessitate tube replacement in PEJ patients. Tube trade-out or removal and aspiration within a 30-day period after tube placement occurred in 28% and 10% of patients, respectively. These complications were significantly more common in PEJ patients than in PEG patients. Because of the increased incidence of tube dysfunction and the failure to prevent aspiration in predisposed patients, PEJ tube placement is not routinely indicated in patients requiring tube feedings.

Value of diagnostic upper endoscopy preceding percutaneous gastrostomy.

Percutaneous gastrostomies, placed endoscopically or radiographically, have supplanted their surgical counterparts in many institutions. Although there are few comparative data, a cost advantage is claimed for the radiographic method, as no endoscopy is required. We performed upper endoscopy on 201 patients prior to attempted percutaneous endoscopic gastrostomy (PEG). The medical records of these patients were reviewed. Data collected included endoscopic findings which precluded gastrostomy, necessitated conversion to jejunostomy, or led to changes in medical management. For a total of 73 patients (36%), findings at pregastrostomy endoscopy led to major changes in medical management, including 35 patients with severe reflux esophagitis, 29 patients with peptic ulcers, and two patients with gastric outlet obstruction. Appropriate treatment of such conditions may improve morbidity, mortality, and cost by reducing length of hospital stay. The authors recommend diagnostic upper endoscopy in patients undergoing percutaneous gastrostomy, regardless of placement method.

Prospective evaluation of a small caliber upper endoscope for colonoscopy after unsuccessful standard examination.

Colonoscopy is unsuccessful in some patients because of a fixed sigmoid loop or anatomical stenoses. We prospectively evaluated 1600 patients undergoing colonoscopy at Virginia Mason Medical Center from December 1, 1986 to November 31, 1987. Thirty-one procedures (1.9%) failed to reach the splenic flexure because of functional or anatomic stenoses. Attempt at pancolonoscopy with a 9.8-mm diameter, 102-cm length endoscope (Olympus XQ) was successful to the right colon in 73% and cecum in 60% of these patients. Two thirds of the successfully intubated patients had clarification of radiographic abnormalities or delineation of additional colon pathology. There were no complications or instrument damages, but limitations included short scope length and small suction channel. We conclude that small diameter upper endoscopes can be used safely and effectively for colonoscopy in a subset of patients in whom conventional colonoscopy is unsuccessful.

Methotrexate induces clinical and histologic remission in patients with refractory inflammatory bowel disease.

STUDY OBJECTIVE: To determine whether methotrexate has anti-inflammatory activity in refractory inflammatory bowel disease. DESIGN: Nonrandomized, open-label, preliminary trial of methotrexate along with standard medications for 12 weeks. SETTING: Referral-based gastroenterology practice. PATIENTS: Twenty-one patients with refractory inflammatory bowel disease (14, Crohn disease; 7, chronic ulcerative colitis); 17 taking variable doses of corticosteroids and 14 on sulfasalazine or metronidazole. Of the 21 patients, 10 had previously failed azathioprine or 6-mercaptopurine trials. INTERVENTIONS: Sulfasalazine and metronidazole were continued and prednisone dose was tapered according to clinical response. Methotrexate was given as a 25-mg intramuscular injection weekly for 12 weeks, then switched to a tapering oral dose if a clinical and objective improvement was noted. MEASUREMENTS AND MAIN RESULTS: Sixteen of twenty-one patients (11 of 14 patients with Crohn disease, 5 of 7 patients with chronic ulcerative colitis) had an objective response as measured by disease activity indices (modified Crohn's Disease Activity Index, 13.3 to 5.4 [P = 0.0001], Ulcerative Colitis Activity Index, 13.3 to 6.3 [P = 0.007]). Prednisone dosage decreased from 21.4 mg +/- 5.6 (SEM) to 5.5 mg +/- 2.0; P = 0.006 and 38.6 mg +/- 6.35 to 12.9 mg +/- 3.4; P = 0.01, respectively. Five patients with Crohn colitis had colonoscopic healing and 4 had normal histology at 12 weeks. In contrast, none of the 7 patients with ulcerative colitis had normal flexible sigmoidoscopies, despite histologic improvement in 5. Side effects included mild rises in transaminase levels in 2 patients, transient leukopenia in 1, self-limited diarrhea and nausea in 2 patients, and 1 case each of brittle nails and atypical pneumonitis. CONCLUSIONS: Although this pilot study is encouraging, further work is needed before methotrexate can be recommended for inflammatory bowel disease.

Bacteremia with gastrointestinal endoscopic procedures.

The authors have reviewed 40 prospective studies of bacteremia with gastrointestinal procedures. Endoscopic procedures with a low mean frequency of bacteremia were esophagogastroduodenoscopy (4.2%), endoscopic retrograde cholangiopancreatography (5.6%), colonoscopy (2.2%), and sigmoidoscopy (4.9%). A higher mean frequency of bacteremia was encountered with esophageal dilation (45%) and variceal sclerotherapy (31%), although the number of patients studied was small. Potentially pathogenic organisms, such as Streptococcus viridans, Staphylococcus aureus, and Staphylococcus epidermidis have been isolated. Recommendations for antibiotic prophylaxis are reviewed. Less cumbersome regimens encourage compliance and are preferred.

Non-traumatic hemobilia.

A case of gastrointestinal bleeding due to hemobilia is presented. Extensive preoperative evaluation, including arteriography, did not unambiguously identify the source of hemorrhage. The differential diagnosis of this treatable cause of gastrointestinal bleeding is discussed.