Sequential endoscopic/laparoscopic management of sickle hemoglobinopathy-associated cholelithiasis and suspected choledocholithiasis.

We reviewed the medical records of 17 patients with sickle hemoglobinopathy-associated cholelithiasis who were candidates for laparoscopic cholecystectomy (LC) between 1991 and 1994. Eight patients with suspected choledocholithiasis (CDL) were identified, all of whom had preoperative endoscopic retrograde cholangiopancreatography (ERCP), which revealed CDL in 3 patients (18%), all of whom had endoscopic ductal clearance. Choledocholithiasis was suspected because of hyperbilirubinemia or serum liver enzyme abnormalities. Incremental hyperbilirubinemia exceeding "baseline" values by > 5 mg/dL was the best predictor of CDL. Subsequent LC was successful with discharge within 2 days of LC in all but one patient, who was converted to open cholecystectomy. This small series suggests that in sickle hemoglobinopathy patients with cholelithiasis (1) CDL is relatively common among patients with an increase above baseline hyperbilirubinemia, (2) bile duct dilatation, alkaline phosphatase, and serum aminotransferase levels are poor predictors of CDL, and (3) sequential endoscopic/laparoscopic management of cholelithiasis and suspected CDL is successful.

Predictors of compliance after hospitalization.

To determine compliance with outpatient evaluation after hospitalization and identify factors that predict postdischarge noncompliance, the charts of 449 patients discharged from the medical service of a university hospital during a 1-month period were reviewed. Those with studies scheduled following discharge were identified and compliance rates determined based on type of study, age, sex, race, and financial classification. Results were subjected to chi-square analysis using 95% confidence intervals. Of the 449 charts reviewed, 48 patients (10.7%) were identified with 59 outpatient studies scheduled. Thirty-one (64.6%) patients underwent their evaluations as scheduled. Thirty-eight (64.4%) of the scheduled studies were completed. Lower compliance rates were found in patients younger than 40, females, blacks, and Medicaid patients, but none of the differences reached statistical significance. As economic pressure continues to move health care to the outpatient setting, patient compliance is becoming an increasingly important factor in the delivery of cost-effective health care. Therefore, identifying accurate predictors of compliance is equally important. Based on the findings of this study, age, sex, race, and financial classification cannot be used as accurate predictors of compliance.

Diagnostic considerations in evaluation of patients presenting with melena and nondiagnostic esophagogastroduodenoscopy.

Proper evaluation of patients with melena and nondiagnostic esophagogastroduodenoscopy is comparatively undefined. We sought to determine the percentage of patients with melena and nondiagnostic upper endoscopy and assess the yield of further evaluation. Of 209 patients presenting with melena, 180 underwent esophagogastroduodenoscopy as the initial study, which was nondiagnostic in 43 cases (24%). Further evaluation was pursued in 30. A presumed source of melena was found in 11 patients (37%), identified by colonoscopy in seven, bleeding scan in three, and barium enema plus flexible sigmoidoscopy in one. Nearly all such defined cases originated from the right colon. Small bowel contrast studies, flexible sigmoidoscopy of barium enema alone, and angiography failed to reveal a source. Our findings suggest that many (24%) patients presenting with melena will have nondiagnostic upper endoscopy; further evaluation reveals a potential source in 37% of this group, with the right colon being the most likely location of pathology; and colonoscopy is the test of choice in this cohort.