Evaluation of sclerosing cholangitis by endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography contributed considerably to diagnosis or subsequent management of two cases of sclerosing cholangitis, In the first patient, sequential studies helped to determine the timing and nature of the surgical intervention that was used. In the second patient, the diagnosis was suggested by ERCP, which led to surgical exploration and biopsy of the common bile duct to confirm the diagnosis. The quality of the films obtained in both patients was excellent. We suggest that ERCP is a relatively noninvasive and accurate means of follow-up in cases of sclerosing cholangitis.

Variation in management based on type of choledochal cyst.

The management of 23 patients treated for choledochal cysts at the Oregon Health Sciences University between 1969 and 1990 is reviewed. The median age was 27 years, with a range from 1 month to 90 years. Seventy-eight percent of patients presented with abdominal pain, and 35% were jaundiced. Three patients presented with cholangitis, two with cyst rupture, and one with recurrent pancreatitis. Nine patients had had previous biliary surgery. The diagnosis was made in all patients with ultrasound and/or cholangiography. Fifteen patients (65%) had type I cysts, 2 had a type II cyst, 5 (22%) had type III cysts, and 1 had a type IV cyst. Stones were present in four (17%) cysts, and all excised cysts were benign. Seventeen patients with type I and II choledochal cysts had complete cyst excision and choledochoenterostomy. Four of five patients with type III cysts had endoscopic cyst incision and drainage, while the fifth patient had transduodenal cyst excision and sphincteroplasty. The patient with a type IV cyst had extrahepatic cyst excision and choledochojejunostomy. There were no operative deaths. Two postoperative complications occurred: cholangitis and a prolonged ileus. All patients had resolution of their pain and jaundice. Two patients had late cholangitis. Cyst excision and choledochojejunostomy are the treatment of choice for types I and II choledochal cysts. Extrahepatic cyst excision and choledochojejunostomy may be adequate treatment for type IV cysts. Endoscopic incision and drainage is appropriate for selected patients with type III cysts.

Solitary rectal ulcer syndrome presenting with rectal prolapse, severe mucorrhea and eroded polypoid hyperplasia: case report and review of the literature.

A case of solitary rectal ulcer syndrome in a 36-year-old woman presenting with severe, persistent mucorrhea and eroded polypoid hyperplasia as the predominant clinical features, who was ultimately noted to have symptoms of rectal prolapse, is presented. Endoscopically, she had multiple (50 to 60) small, whitish polypoid lesions in the rectum that were initially misinterpreted as being a carpeted villous adenoma, juvenile polyposis or atypical proctitis. The lesions were treated with argon plasma coagulation with resolution, but a solitary rectal ulcer developed. The patient then admitted to a history of massive rectal prolapse over the preceding six months and underwent surgical treatment. Severe mucorrhea as the presenting feature and the presence of multiple polypoid lesions consistent with a histological diagnosis of eroded polypoid hyperplasia make the present case unique.

NSAID-induced small bowel diaphragms and strictures diagnosed with intraoperative enteroscopy.

Nonsteroidal anti-inflammatory drugs are known to cause mucosal damage in the stomach and duodenum, which may lead to hemorrhage and perforation. However, these medications may also cause damage in the more distal small bowel. Due to the location of these lesions, currently available diagnostic testing may yield false negative results. Two cases of nonsteroidal anti-inflammatory drug-induced small bowel diaphragms presenting as obscure gastrointestinal hemorrhage and recurrent small bowel obstruction, respectively, are discussed. Intraoperative enteroscopy was used to confirm this diagnosis after other diagnostic tests failed to identify the etiology. This procedure may increase the accuracy of exploratory laparotomy in these challenging cases.

The pansigmoidoscope: one year's experience in a gastrointestinal diagnostic unit.

Since May 1976, the Olympus pansigmoidoscope has been available for routine use at the University of Oregon Health Sciences center. Two hundred sixty-five examinations were performed over the next year. The average distance examined was 49 cm. Time per examination ranged from 3 to 15 minutes, with an average of 8 minutes. Preparation consisted of one or two tap water enemas, except in known inflammatory bowel disease where no preparation was given. No patient received sedation and there were no complications. Small biopsy (2.8 mm), large biopsy (4.0 mm), "hot biopsy" and polypectomy were performed when indicated. The procedure was most helpful for the following indications: 1) differential diagnosis and follow-up of inflammatory bowel disease, 2) hematochezia, 3) evaluation of abnormal barium enema, 4) left-sided polypectomy, 5) diarrhea with normal barium enema, and 6) guaiac-positive stools. It was of no value in patients with abdominal pain with normal barium enema. Comparing the frequency of examinations this year with last year we found a 50% decrease in use of the rigid (25 cm) sigmoidoscope (538 to 270 exams) and a 98% decrease in use of the MB2 (100 cm) colonoscope (80 to 2 exams).

Tiny snares prove safe and effective for removal of diminutive colorectal polyps.

The efficacy of two new tiny snares has been evaluated for removal of diminutive (7 mm or less) colorectal polyps. The small size of the snares facilitates direct placement over a polyp, after which resection can be performed using monopolar current. Data were prospectively collected on 183 polyps, 2 to 7 mm in diameter, encountered in 90 patients. Polyp diameter, location relative to the splenic flexure, and histologic characteristics were noted, as were retrieval rate and complications. Ninety-four percent of the polyps could be removed with a tiny snare, and 88% of these were recovered. Forty percent of the polyps were located proximal to the splenic flexure, and 69% were neoplastic. The only complication was major hemorrhage in 1 patient (0.5%), in whom snare polypectomy without current application was used. Tiny snares can effectively and safely be used to remove diminutive colorectal polyps, and they may make "hot biopsy" forceps obsolete.

Familial multiple congenital esophageal rings: report of an affected father and son.

Multiple esophageal rings are a very unusual cause of dysphagia. We report a case of a 35-yr-old male with multiple esophageal rings and severe dysphagia, whose father had similar symptoms. Our patient underwent esophageal dilation on one occasion and is asymptomatic at 1-yr followup. We speculate that multiple esophageal rings may be of congenital origin.

Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a standard endoscope.

BACKGROUND: The use of push enteroscopy to evaluate patients with obscure gastrointestinal bleeding has increased in recent years, and diagnostic yield has been reported to be 50% to 65%. This yield may be an overestimate of accuracy, as some lesions found during enteroscopy are within reach of a standard endoscope. METHODS: Ninety-five patients underwent push enteroscopy for obscure gastrointestinal bleeding. There were 58 men and 37 women with a mean age of 67 years (range 32 to 93 years). Diagnostic yield and patient outcome were assessed. RESULTS: A suspected source of bleeding was found in 39 of 95 patients (16 of these patients had endoscopic treatment of their lesions). Proximal lesions (at or above the main duodenal papilla) accounted for 25 of 39 sources (64%), including Cameron ulcers and arteriovenous malformations of the stomach/proximal duodenum. Distal lesions accounted for 14 of 39 sources (36%) with arteriovenous malformations (n=0) being most common. Patients who underwent some form of treatment (medical, surgical, or endoscopic) because of an enteroscopic finding had a statistically better outcome than patients without a lesion (73% vs. 47%, p < 0.05). CONCLUSIONS: Push enteroscopy identified a presumed bleeding source in 41 % of patients with obscure gastrointestinal bleeding. However, 64% were within reach of a standard endoscope. Repeat standard endoscopy should be considered before push enteroscopy for obscure gastrointestinal bleeding, and during enteroscopy meticulous attention should be given to the proximal gastrointestinal tract in addition to the distal duodenum and jejunum.

Endoscopic management of postoperative biliary leaks: review of 77 cases and report of two cases with biloma formation.

Biliary leaks are uncommon complications of abdominal surgery. Left untreated, they may result in significant morbidity and mortality. The traditional treatment has been surgical, but several authors have reported successful endoscopic management. We review 77 cases of endoscopically managed postoperative biliary leaks reported in the literature over the past 15 yr. Endoscopic treatment was technically successful in 95% of cases, and resulted in biliary leak healing in 82%. Cystic stump leaks had a better prognosis for healing compared with common bile duct or hepatic duct leaks. We also present two additional cases of postoperative biliary leaks with biloma formation successfully treated with endoscopic stent placement. Our experience lends additional support to endoscopic management as the preferred approach to postoperative biliary leaks.

Obstructive jaundice after bone marrow transplantation.

Jaundice after bone marrow transplantation is usually a consequence of graft versus host disease. Reported is a patient who presented with obstructive jaundice several months after a successful marrow allograft. Despite a benign bone marrow examination, abdominal ultrasound, upper gastrointestinal series, and endoscopic biopsy were utilized to diagnose recurrent leukemia at the pancreatic head and descending duodenum. The entities of graft versus host disease as related to jaundice, and gastrointestinal leukemia, in the presence of a "remission" bone marrow, are reviewed.

Use of a variable-stiffness colonoscope allows completion of colonoscopy after failure with the standard adult colonoscope.

BACKGROUND AND STUDY AIMS: Experts fail to reach the cecum in 2 - 10% of colonoscopies. The purpose of this case series was to evaluate the efficacy of a small-caliber, variable-stiffness colonoscope in patients with incomplete colonoscopy. PATIENTS AND METHODS: The variable-stiffness colonoscope (Olympus America XPCF-140AL) was used by the same examiner to reattempt colonoscopy immediately in all patients in whom colonoscopy to the cecum with the standard colonoscope was incomplete. RESULTS: Sixteen of 385 attempted colonoscopies (4.2%) did not reach the cecum with the standard colonoscope due to looping (n = 12), fixed angulation of the sigmoid colon (n = 3), and diverticulosis (n = 1). The procedures were deemed a failure after a mean of 28 min, despite the use of abdominal pressure and positional change in all patients. Fifteen of the 16 patients (94 %) had a complete colonoscopy with the variable-stiffness colonoscope. One patient had an incomplete colonoscopy with the variable-stiffness colonoscope due to an obstructing mass in the transverse colon that was not reached by the standard colonoscope. With the variable-stiffness colonoscope, the mean time to cecal intubation was 10.3 min; four patients (25 %) required a change in patient position, and six patients (37.5 %) required abdominal pressure. CONCLUSIONS: A variable-stiffness colonoscope allowed completion of colonoscopy in all patients without obstruction who had an incomplete colonoscopy with the standard colonoscope. Further study is needed to determine whether the variable-stiffness colonoscope should be used routinely for colonoscopy.

Total peroral intraoperative enteroscopy for obscure GI bleeding using a dedicated push enteroscope: diagnostic yield and patient outcome.

BACKGROUND: Intraoperative enteroscopy is an effective diagnostic and therapeutic method in selected patients with obscure gastrointestinal (GI) bleeding. The passage of a colonoscope orally and then rectally or the use of multiple enterotomies, has been used to completely inspect the small bowel. However, the development of dedicated enteroscopes allows complete inspection using the peroral route. AIM: The aim of the study was to assess the diagnostic yield, patient outcome, and success in reaching the terminal ileum using a video enteroscope passed orally during intraoperative enteroscopy. METHODS: The hospital charts of 12 patients who underwent intraoperative enteroscopy for GI bleeding of obscure origin and 2 patients with a known source (angioectasias) who underwent evaluation to determine extent were retrospectively analyzed. RESULTS: The terminal ileum was reached in 13 of 14 patients (jejunal stricture in 1 patient). Of the patients with bleeding of obscure origin (n = 12) a source was identified in 7 (angioectasias 4, lymphoma 1, carcinoid 1, nevuslike lesion 1). Surgical therapy was performed in these 7 patients and resulted in no further bleeding in 5. Bleeding recurred in 4 of the 5 patients who had no source identified during intraoperative enteroscopy. Of the 2 patients undergoing intraoperative enteroscopy to evaluate extent of angioectasias, additional angioectasias were found in 1 patient; both patients underwent surgical resection, and 1 patient had recurrent bleeding. Complications included serosal tears, 3 (2 requiring resection); avulsion of superior mesenteric vein, 1; postoperative congestive heart failure, 2; azotemia, 1; and prolonged ileus, 1. There were no deaths. CONCLUSIONS: The terminal ileum was reached 93% of the time with intraoperative enteroscopy. For patients with GI bleeding of obscure origin the diagnostic yield of intraoperative enteroscopy was 58%. Major operative morbidity occurred in 4 patients.

Percutaneous transhepatic gallstone removal by needle tract.

A percutaneous transhepatic cholangiogram tract was used to visualize a large stone in the common duct; following the tract's dilation, the stone was crushed and partially removed. Fragments were flushed and also passed spontaneously into the duodenum. The approach described offers a feasible alternative to surgery.

Endoscopic treatment of postoperative biliary strictures.

Benign postoperative biliary tract strictures may present with jaundice and/or cholangitis. Surgical reconstruction of these usually proximal biliary strictures carries high morbidity and mortality. In addition, recurrences following surgery are common. We attempted endoscopic therapy in 29 consecutive patients with benign biliary strictures, by the placement of one or two large-bore 10 French endoprostheses. The procedure was successful in 27 out of 29 (93%) patients. All 27 had rapid clearance of jaundice and/or cholangitis. Clinical follow-up of 21 patients for at least 6 months (range 6 months to 4 years) shows that 19 out of 21 have good (3) or excellent (16) results. There was no morbidity or mortality associated with the procedure. Although placement of an endoprosthesis in this group of patients is technically difficult, we believe it should be considered as the initial therapeutic modality in this clinical situation.

Cardiopulmonary risk of esophagogastroduodenoscopy. Role of endoscope diameter and systemic sedation.

The impact of endoscope diameter and the presence of systemic sedation on the cardiopulmonary risk of esophagogastroduodenoscopy was investigated. One hundred and forty-six patients undergoing elective esophagogastroduodenoscopy were randomly assigned to one of three groups which differed in either endoscope diameter or use of sedation: group 1 (8.5-mm endoscope with no sedation), group 2 (8.5-mm endoscope with diazepam), and group 3 (11.5-mm endoscope with diazepam). Esophagogastroduodenoscopy was tolerated best by group 2, and this group had the fewest electrocardiographic changes observed on a Holter recording during esophagogastroduodenoscopy. The incidence of electrocardiographic changes during esophagogastroduodenoscopy correlated with patient tolerance (p less than 0.001) and the use of the smaller endoscope (p less than 0.05). The most common arrhythmia was sinus tachycardia (49 patients), but more serious electrocardiographic changes were observed in 21 patients. Serious arrhythmias were more common in patients with a prior history of cardiovascular disease compared with patients with no such history (30% vs. 6%, p less than 0.001). Arterial oxygen desaturation (measured by ear oximetry) during intubation and esophagogastroduodenoscopy was usually modest (2%-5%). However, 16 patients receiving diazepam experienced high levels of desaturation exceeding 7%; this small group of patients also experienced more electrocardiographic changes than other patients. The use of diazepam sedation and an 8.5-mm endoscope may offer the safest and most comfortable combination for most patients undergoing esophagogastroduodenoscopy. Diazepam sedation, however, may represent a potential danger to a small number of patients with marginal baseline arterial saturation.

Unsedated peroral endoscopy with a video ultrathin endoscope: patient acceptance, tolerance, and diagnostic accuracy.

OBJECTIVE: The aim of this study was to assess patient tolerance of unsedated routine upper endoscopy using a 6-mm ultrathin (UT) video endoscope (Olympus XGIF-N200H) and to compare its optical quality to a standard endoscope (Olympus GIF100). METHODS: A total of 62 outpatients were recruited for unsedated UT endoscopy using topical spray followed by sedated endoscopy using a standard endoscope. After unsedated endoscopy, patients were asked to complete a questionnaire assessing tolerance. When both endoscopies were completed, the endoscopist recorded findings and optical quality of the UT. RESULTS: Of 62 patients, 19 refused unsedated endoscopy because of anxiety (12), fear of gagging (3), and unwillingness to be study patients (4). TOLERANCE: Of 43 patients, 37 (86%) had a complete, unsedated UT exam (five patients did not have a GIF100 exam). During insertion, 60% of the patients reported none/mild discomfort, whereas, during the remainder of the examination, 73% had none/mild discomfort. Of 37 patients, 30 (81%) were willing to undergo future unsedated endoscopy with the UT and they tolerated UT endoscopy better than the patients who were unwilling (none/mild discomfort: 83% vs 29%). Of 43 patients, six (14%) failed UT endoscopy because of severe gagging (all were male, mean age 44 yr). OPTICS: Optical quality was rated as good 84%, 65%, and 78% of the time in the esophagus, stomach, and duodenum, respectively. Optical quality was diminished by excessive fluid and tenacious secretions. The UT missed five of 59 lesions: three hiatal hernias and two gastric erosions. CONCLUSION: A total of 69% of outpatients agreed to undergo peroral unsedated endoscopy with a UT endoscope. A total of 86% of patients tolerated a complete unsedated examination, and 81% of these were willing to undergo future unsedated examinations. Diagnostic accuracy of this ultrathin video endoscope was good, with 92% of lesions discovered when compared with a standard instrument.

Pouch ileitis: report of a case with severe systemic manifestations.

A 28-year-old man with chronic ulcerative colitis had a proctocolectomy with creation of a continent ileostomy. Six months later, he developed a severe systemic illness characterized by malaise, 24-lb. weight loss, fever, night sweats, arthralgias, bloody diarrhea, and problems with ileostomy function. On endoscopy, the pouch showed erythema, edema, friability, and ulceration; on biopsy, there was severe mucosal disruption with ulceration into the submucosa. Features consistent with chronic ulcerative colitis were also present. Laboratory investigation ruled out other causes of the illness so that a diagnosis of pouch ileitis was made. The patient responded dramatically to a 10-day course of metronidazole and remains well 2 years later. In patients with continent ileostomy after proctocolectomy for chronic ulcerative colitis, inflammation of the pouch may be associated with a severe systemic illness. The pathogenesis is unclear, but may involve the interaction of colonic type bacterial flora with ileal mucosa in immunologically susceptible patients.

Intramural hematoma of the small intestine presenting with major upper gastrointestinal hemorrhage. Case report and review of the literature.

We report a case of an anticoagulated patient presenting with a massive upper gastrointestinal hemorrhage, abdominal pain, and a palpable abdominal mass, demonstrated to be an intramural hematoma of the jejunum. Approximately two-thirds of intramural hematomas of the small intestine are preceded by abdominal trauma with the remainder associated with pancreatic disease, alcoholism, unknown causes, or clotting defects. Spontaneous occurrence of intramural hemorrhage is uncommon. Of the varied clinical presentations, gastrointestinal bleeding, previously thought unusual, is seen in 30% of cases, although major hemorrhage is rare. Conversely, reports of intramural hematoma of the small intestine as a case of major gastrointestinal bleeding has not been recognized. A review of the literature follows, and the authors stress that abdominal trauma should raise the possibility of an intramural hematoma of the small bowel.

Possible foodborne transmission in a case of pseudomembranous colitis due to Clostridium difficile: influence of gastrointestinal secretions on Clostridium difficile infection.

A 78-yr-old woman with a history of hypochlorhydria was found to have pseudomembranous colitis due to Clostridium difficile. She had not received previous antimicrobial therapy. Her onset of disease followed ingestion of possibly contaminated canned salmon, suggesting possible oral transmission of disease. We assessed the possibility of ingested Clostridium difficile organisms or cytotoxin surviving passage through the upper gastrointestinal tract. Normal gastric juice, hypochlorhydric gastric juice, and duodenal secretions were obtained from volunteers and tested for their ability to kill Clostridium difficile organisms or inactivate toxin. These in vitro studies indicated that the primary upper gastrointestinal barriers for ingested Clostridium difficile and cytotoxin were pH-dependent. We suggest that oral transmission of disease due to Clostridium difficile may occur in hypochlorhydric patients.

Hepatic abscesses as a complication of the sump syndrome: combined surgical and endoscopic therapy. Case report and review of the literature.

The "sump syndrome" is an unusual complication of side-to-side choledochoduodenostomy in which the portion of the common bile duct distal to the anastamosis acts as a sump and may collect bile, stones, food, and other debris. Partial or complete obstruction of the stoma and resultant bacterial proliferation may result and lead to recurrent cholangitis or pancreatitis. A single hepatic abscess as a complication of the sump syndrome has been reported only once. We have recently seen a patient presenting with multiple hepatic abscesses as a complication of the sump syndrome. This is the first report of endoscopic treatment of this syndrome associated with a hepatic abscess. The literature on the endoscopic approach to this problem will be reviewed.