A supervised training program in flexible sigmoidoscopy: evaluating skills from residency training to clinical practice.

To assess the effectiveness of a training program in flexible sigmoidoscopy for family practice residents, we prospectively studied the performance of four residents during their training and after graduation. One hundred and four training exams performed with the assistance of an experienced gastroenterologist were compared with 118 unassisted post-training, post-residency exams. The mean depth of insertion for the post-training period was 51.1 +/- 1.2 cm, which was significantly greater (P less than .05, Student's t test) than the mean training period depth of 47.6 +/- 1.2 cm. There was no significant difference in the identification of polyps or cancer between the training and post-training periods. The mean duration of an exam was 17.3 +/- 0.6 minutes in the post-training period. No significant complications were encountered in either period. The residency trained family physicians obtained results similar to those reported by trained endoscopists in depth of examination and pathology detected, although their examinations required more time. We conclude that this model of training was effective in the development of flexible sigmoidoscopy procedural skill for family practice residents.

Mallory-Weiss syndrome in a 16-week-old infant.

The Mallory-Weiss syndrome is a recognized cause of upper gastrointestinal bleeding in adults. It is a very rare entity in the pediatric age group. The case discussed outlines the reasons for its rarity and the modalities used for its diagnosis.

Advances in enteral nutrition techniques.

The increasing use of enteral nutrition in hospitals has led to an expanded role for the gastroenterologist and surgeon in providing enteral access. New concepts in immunonutrition and gut support in critically ill patients have popularized early postoperative feeding. There is an ongoing need to update physicians on the diverse enteral access techniques now available. In addition to standard percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) techniques, this review focuses on reflux prevention through double-lumen feeding-suction tubes, and describes the use of steerable catheters for rapid insertion of nasojejunal and PEJ tubes without endoscopy. Low-profile "button"-type devices, one-step button placement, replacement gastrostomy devices, and special enteral techniques for patients with cancer are also reviewed.

Flexible fiberoptic sigmoidoscopy training for primary care physicians: results of a 5-year experience.

The first 5 years of a flexible fiberoptic sigmoidoscopy (FFS) training program for primary care physicians was analyzed in an attempt to assess clinical competence and develop a procedure learning curve. A total of 47 primary care physicians (26 third-year family practice residents, 15 family practitioners, and 6 internists) were successfully trained in 60-cm FFS by five gastroenterologists. Didactic teaching methods included 5 hours of videotapes, slides, endoscopic models, and the use of a photo atlas. Following a patient demonstration, each trainee completed 25 examinations supervised with a teaching attachment. Criteria used to assess trainee competence included unassisted length of scope insertion and examination duration. Mean depth of scope insertion was 35.9 cm for the first five examinations, increasing to a mean of 51.7 cm for the final five examinations. Average examination duration decreased from 19.1 min for examinations 1 through 5 to 17.0 min for examinations 21 through 25. Out of 1236 examinations, one or more polyps were found in 222 patients (18.0%). Carcinoma was found in 15 of 1236 examinations (1.4%). In summary, experienced endoscopists can teach primary care physicians to perform 60-cm FFS. Completion of 25 supervised cases appears to be adequate for achieving technical competence in flexible fiberoptic sigmoidoscopy.

Morphological observations on the normal human cardiac glands.

The majority of human cardiac glands that lie immediately distal to the termination of esophageal epithelium are compound or branched tubular glands. They empty into overlying gastric pits. The glands of this region are often organized into lobule-like complexes by the surrounding connective tissue of the lamina propria. The secretory tubules contain mucous cells, parietal cells and endocrine cells. The mucous cell is the most common cell type observed and appears to comprise two populations. The majority are pyramidal in shape and show numerous spherical, electron-dense secretory granules. Profiles of rough endoplasmic reticulum are observed scattered throughout the cytoplasm and Golgi complexes occupy a supranuclear position in relation to forming secretory granules. Morphologically this cell type appears similar to the mucous neck cell of the fundus. Secretory granules of a second mucous cell type are mottled in appearance and show an area of increased electron density near the limiting membrane. Parietal cells are observed and appear identical to those in the fundus. The large number of endocrine cells present raises questions concerning the traditional concept of the function of these particular glands.

Protective effect of cimetidine on aspirin-induced gastric mucosal damage.

Aspirin alters the gastric mucosal barrier as measured by ionic flux and potential difference. The effect of cimetidine on aspirin-induced alterations in gastric mucosa was studied in five normal male volunteers. Aspirin effects were studied with and without previous treatment with cimetidine. Mean (+/- SEM) basal potential difference was -48 +/- 1 mV. After 600 mg of aspirin in 1 dl of isotonic saline, potential difference decreased in 10 min to -39 +/- 1 mV (P less than 0.001) and returned to baseline within 60 min. Control biopsies showed 2% damaged mucosal cells compared with 20% damaged at the time of maximal drop in potential difference (P less than 0.001) after aspirin. Recovery to 9% damage occurred by 60 min. In subjects pretreated with 300 mg cimetidine, potential difference rose during 1 h to -62 +/- 1 mV (P less than 0.001). After aspirin potential difference fell to -48 +/- 1 mV compared with -39 +/- 1 mV with aspirin alone (P less than 0.01) and returned to -62 +/- 1 mV at 60 min. The cimetidine-treated group showed 4% mucosal damage at the peak potential difference fall after aspirin, significantly less (P less than 0.02) than in the untreated subjects.

Effect of aspirin and acid on human jejunal mucosa. An ultrastructural study.

To determine the effects of aspirin and hydrochloric acid on human jejunal mucosa, three obese patients with a small intestinal bypass that opened on the abdominal wall as a mucous fistula were studied. An 80-mM solution of HCl, a 40-mM suspension of aspirin (equivalent to two tablets in a glass of water), and a combination suspension of 40 mM aspirin plus 40 mM HCl damaged a mean +/- SE of 26 +/- 13% (P less than 0.05), 24 +/- 5% (P less than 0.05), and 29 +/- 5% (P less than 0.05) of jejunal villi, respectively, 5 min after administration. By 60 min after instillation, considerable recovery had occurred. Scanning electron microscopy revealed focal villous tip erosion and erythrocyte extrusion after all test solutions. In conclusion, aspirin, 40 mM, physiologic concentration of hydrochloric acid, and the combination of acid plus aspirin are each capable of damaging human small intestinal mucosa on direct contact.

A scanning electron microscopic study of normal human oxyntic mucosa using blunt dissection and freeze fracture.

Biopsies from the fundic mucosa of healthy volunteers were examined by scanning electron microscopy following blunt dissection and freeze fracture. The mucosal surface exhibited a cobblestone appearance. With increased magnification, microvilli could be demonstrated on the luminal surface of individual surface cells. Blunt dissection of the gastric mucosa revealed tubular gastric pits descending from the surface until they opened into branched tubular gastric glands. The gastric glands are irregular in outline due to the knoblike projections of individual parietal cells. The internal structure of the component cells also was examined with the scanning electron microscope following freeze fracture. Mucous granules were observed in the apical portion of surface epithelial cells. Lumina of parietal cell canaliculi were found to be continuous with the lumen of the gastric glands. Pepsinogen granules could be seen throughout the cytoplasm of chief cells. The blunt dissection-freeze fracture technique utilizing the scanning electron microscope allows, for the first time, a three-dimensional view of human gastric mucosa, including the gastric pits and glands as well as some of the internal architecture of component cells.

Ultrastructure of the human pyloric glands with emphasis on the mucous cell component. Part I.

The human pyloric glands are simple or branched tubular glands which spiral through the connective tissue of the lamina propria. They are comprised of three cell types: the pyloric gland (mucous) cell, the parietal cell, and endocrine cells. The mucous cell is the most common cell type in the human pyloric glands and is characterized by an abundance of secretory granules. The secretory granules are usually round in shape and vary considerably in diameter. They are membrane-bound and comprise a heterogeneous population. The larger granules contain a light staining amorphous material and often possess an area of increased electron density near the limiting membrane of the granule giving them a mottled appearance. A smaller, more electron-dense secretory granule also is found both in relation to the Golgi complex and cell apex. The morphological observations indicate that the mechanism of mucin production by the mucous cells of the human pyloric glands may be similar to that reported in other mucin-secreting cells.

Aspirin-induced ultrastructural changes in human gastric mucosa: correlation with potential difference.

Aspirin breaks the gastric mucosal barrier. We studied the effect of aspirin on this barrier, correlating changes in potential difference and ultrastructure. Mean control potential difference for seven subjects was -48 +/- 1.0 mV. Oral aspirin, 600 mg in 100 ml of saline, reduced potential difference to -39 +/- 1.4 mV (P less than 0.001) within 10 minutes. Gastric biopsies were taken during control, aspirin- instillation, and recovery periods. Damage was present in all biopsies after aspirin. Light microscopy showed focal cell disruption, loss of mucous granules, and apical membrane rupture. Transmission electron microscopy showed intact tight junctions. Scanning electron microscopy showed loss of normal cobblestone cell apices, giving a honeycombed surface. Ten minutes after aspirin, 25% of surface epithelial cells were damaged. Marked recovery was noted at 1 hr, with a normal potential difference and only 9% cell damage. We conclude that single "routine" doses of aspirin cause focal damage to normal human gastric mucosa.

Incidence of gastric lesions in patients with rheumatic disease on chronic aspirin therapy.

Endoscopy was done in 82 patients with rheumatic disease who were receiving chronic aspirin therapy. Fifty-eight patients were taking at least eight aspirin tablets daily for 3 or more months; 24 patients were taking, in addition to the aspirin, a maximum of one other antiinflammatory, nonsteroidal medication. Endoscopy in 45 normal subjects not taking aspirin showed no ulcers or erosions and a 4% incidence of gastric erythema. In the 82 patients with rheumatic disease, 14 (17%) had gastric ulcers, 33 (40%) had gastric erosions, and 62 (76%) had gastric erythema. Regular aspirin and buffered aspirin users had an ulcer incidence of 23% and 31% respectively, compared with a 6% incidence in enteric-coated aspirin users (P less than 0.05). One third of all patients with gastric ulcer had no gastrointestinal symptoms. Patients taking chronic aspirin therapy for rheumatic diseases have a higher than suspected incidence of gastric ulcer and erosions. Gastric ulcer may exist without symptoms in such patients.