Obliteration of symptomatic Schatzki rings with jumbo biopsy forceps (with video).

A Schatzki ring is a submucosal, fibrotic thickening located at the gastroesophageal junction. Endoscopic treatment traditionally involves disruption of the ring. Many approaches have been described including bougies, balloons, biopsies, and diathermic monopolar incision. While all of these approaches are effective in the short-term, recurrence is common. The objective of our study was to evaluate the feasibility of complete excision of the ring using jumbo cold biopsy forceps. Our main outcome measurements were the feasibility, safety, and efficacy of complete obliteration of Schatzki rings using jumbo cold biopsy forceps. We designed an observational study using a standard protocol for patient management and data collection using a university hospital as our setting. We followed 10 patients with dysphagia due to a Schatzki's ring, six of whom had previously undergone bougienage or balloon dilation. Five patients were on maintenance therapy with a proton pump inhibitor and one with an H2 blocker. Complete endoscopic obliteration of the Schatzki rings with a cold jumbo biopsy forceps was achieved in all 10 patients requiring a mean of 9.8 biopsies (range 8-12). Omeprazole (20 mg twice daily) was prescribed after the procedure. All 10 patients demonstrated improvement in dysphagia after treatment, which persisted during a mean follow-up time of 379 days (range 63-496 days). There were no serious complications. The limitations of our study include lack of a control group, a small sample size, and being a single-institution study. We concluded that complete Schatzki ring obliteration with jumbo cold biopsy forceps is a safe, feasible, and effective endoscopic treatment.

Comparison of PCR and common clinical tests for the diagnosis of H. pylori in dyspeptic patients.

Helicobacter pylori has been recognized as a major gastric pathogen. The objective of this study was to assess the diagnostic value of common clinical tests to detect H. pylori infection, by comparison with PCR. Serum and gastric biopsy specimens from 106 dyspeptic patients were examined. Serology was performed with Pyloriset Dry test, and biopsies were examined histologically, for rapid urease activity and PCR amplification of an ureA gene segment of H. pylori. PCR primers were specific for H. pylori and required at least 1.47 pg of H. pylori DNA, corresponding to about 800 bacterial cells. According to serology, histology, rapid urease, and PCR, positive results were respectively found in 56%, 86%, 64%, and 85% of dyspeptic patients, primarily with gastritis. Relative to PCR, the sensitivity (and specificity) was 55% (38%) for serology, 86% (13%) for histology, 70% (69%) for urease. When combining histology and urease, Bayesian analysis of data indicated no advantage of using combined methods over rapid urease test alone. Histology should not any longer be considered a gold standard test for Helicobacter pylori. Urea breath test still seems the first option for non invasive diagnostic. If an invasive diagnostic is justified, highly specific and sensitive molecular methods should be used to examine specimens.

Modification of Christensen urease test as an inexpensive tool for detection of Helicobacter pylori.

About half the world population is infected with Helicobacter pylori. Most live in developing countries where clinical studies face the constraints of high costs of imported rapid diagnostic tests. In this work, we describe and validate a simple local urease test (LUT) to determine the presence of the bacterium in gastric biopsies, and report the incidence of infection among symptomatic patients in Caracas, Venezuela. Statistical comparison of LUT and CLOtest (Delta West, Bentley, Australia) (N = 216 patients) showed that the probability of 95% agreement between the two test was 0.936. Overall incidence of infection determined by the LUT was 65% (N = 229), and it was higher in patients from public (72%; N = 153) than from private (50%; N = 76) hospitals (p = .001). Therefore, the incidence of infection differs in two socioeconomic groups that coexist in the same city. LUT may represent an affordable tool in clinical studies needed to identify social factors that increase the risk of infection by H. pylori.

Dysphagia and lower esophageal sphincter abnormalities after proximal gastric vagotomy.

We studied 96 patients subjected to elective proximal gastric vagotomy for intractable duodenal ulceration. Dysphagia was a frequent finding and occurred in 32 percent. It appeared in the immediate postoperative period and usually lasted for 1 to 2 months without any abnormalities in lower esophageal sphincter function. In five patients, dysphagia was severe and, although transient, was associated with changes in lower esophageal function simulating those observed in achalasia. The mechanism of these motor abnormalities is probably due to a reversible neuromuscular dysfunction of the lower esophageal sphincter.

Endoscopic therapy of pancreatic disease in children.

The advent of endoscopic retrograde cholangiopancreatography (ERCP) has revolutionized the approach to the diagnosis and management of pancreatic disorders in adults. In the past 5 years, endoscopic pancreatic therapy in children has moved from an investigational concept to a practical service provided by specialized centers. When performed by experienced endoscopists, therapeutic pancreatography can be successfully performed in a selected group of children with a low rate of complications.

Endoscopic retrograde cholangiopancreatography.

Endoscopic retrograde cholangiopancreatography has been widely applied as a diagnostic and therapeutic procedure in adult patients with pancreacticobiliary disorders and has recently become an accepted modality in pediatrics. This article reviews the general concepts of diagnostic endoscopic retrograde cholangiopancreatography in children and specific therapeutic interventions and results in different diseases.

Papillary stenosis.

The present state of papillary stenosis is reviewed. ERCP manometry has become the most important means of evaluating sphincter of Oddi dynamics. Pressure measurements in the sphincter segment appear useful to differentiate patients with sphincter of Oddi dysfunction from patients with an organic stenosis. The author's experience with sphincter of Oddi manometry, with endoscopic sphincterotomy and hydrostatic balloon dilation of the sphincter of Oddi, and the results of an international inquiry, are presented.

Endoscopic retrograde cholangiopancreatography in children.

In the past two decades, the possibility to visualize the biliary tree and the pancreatic duct using endoscopic retrograde cholangiopancreatography (ERCP) has substantially influenced evaluation and treatment of adult patients with suspected pancreaticobiliary disease. Development of pediatric duodenoscopes, expansion of indications for the procedure in children, and availability of newly skilled pediatric endoscopists have resulted in an increasing number of these procedures being performed in children. Operative endoscopic procedures are also applicable to children and adolescents; techniques such as endoscopic sphincterotomy, biliary drainage, common bile duct stone and pancreatic duct stone extraction, implantation of endoprosthesis, and pancreatic pseudocyst drainage are beginning to be used in children, with an overall success rate similar to that seen in adult patients. Techniques, indications, complications, and diagnostic and therapeutic applications of ERCP in the pediatric population are defined.

Motor function abnormalities in acute caustic esophagitis.

Severe motor abnormalities in the human esophagus injured by acid correlated with the degree of mucosal esophageal damage observed by esophagoscopy. In mild caustic esophagitis, motor function remained normal. In severe esophagitis, motor alterations included decrease or absence of high resting pressure in the lower esophageal sphincter with normal swallowing response. In the body of the esophagus, manometric findings were variable and consisted of high resting esophageal pressure, absence of motor response after swallowing, nonperistaltic contraction, and delayed swallowing response. At follow-up motility studies 1 month after injury, esophageal motor function had returned to normal. We suggest that these abnormalities, which could be related to edema or a transient damage of mucosal sensory nerves, contributed to dysphagia.

[Interaction of cimetidine and metoclopramide on the lower esophageal sphincter in man]. / Interacción de la cimetidina y la metoclopramida en el esfinter esofágico inferior del humano.

The purpose of this study is to evaluate the effect of Cimetidine and Metoclopramide on human lower esophageal sphincter (LES) pressure. Intravenous Metoclopramide in a bolus injection (0.3 mg/Kg or a maximal dose of 20 mg) produced an increase of LES pressure from 20,8 +/- 3,1 mmHg to a peak response of 42,0 +/- 5,0 mmHg. Intravenous Cimetidine in a bolus injection of 300 mg failed to alter basal LES pressure and LES response to Metoclopramide. Cimetidine in continuous infusion (100 mg/h) also failed to alter basal LES pressure and LES response to intravenous Metoclopramide. These studies suggest that: (1) Human LES pressure increases in response to intravenous Metoclopramide; (2) H2-Antagonism with Cimetidine has no effect on the human LES basal pressure; and (3) The H-2 receptors have no apparent role in the human LES response to Metoclopramide.

Acetic acid improves identification of remnant islands of Barrett's epithelium after endoscopic therapy.

BACKGROUND: Instillation of acetic acid onto the uterine cervix at colposcopy has been used for many years to highlight dysplastic areas and thereby enhance the ability to obtain targeted biopsy specimens. As part of an ongoing trial of multipolar electrocoagulation for Barrett's esophagus, we sought to develop a simple technique to identify small islands of residual specialized columnar epithelium after treatment. METHODS: In 21 consecutive patients, 5 to 10 mL of 1.5% acetic acid was sprayed onto the distal esophagus using a spray catheter, followed immediately by spraying 50 mL of tap water. RESULTS: Initially, a whitish coloration developed in both esophageal and gastric epithelia. After 2 to 3 minutes, the esophageal squamous mucosa remained white but the columnar epithelium became reddish. Remnant islands of Barrett's epithelium were outlined by a white rim. CONCLUSION: Acetic acid instillation enhances the ability to detect small or indistinguishable remnant islands of columnar epithelium after endoscopic treatment of Barrett's esophagus. This method is safe, rapid, and inexpensive.

Late results in patients with Schatzki ring treated by endoscopic electrosurgical incision of the ring.

In 17 ambulatory patients with severe intermittent dysphagia an endoscopic electrosurgical radial incision of a Schatzki ring was made with a modified straight retractable sphincterotome. The incision was successfully accomplished with immediate relief of dysphagia in all patients. Fourteen patients remain asymptomatic with a mean follow-up of 46 months after the first treatment. Three patients required a second incision and they have been asymptomatic for more than 24 months. There was one mild bleeding episode. Endoscopic electrosurgical incision of the Schatzki ring is an effective therapeutic modality in selected patients.

Hypertensive pancreatic duct sphincter as a cause of pancreatitis. Successful treatment with hydrostatic balloon dilatation.

Four patients with recurrent episodes of acute pancreatitis, despite surgical sphincteroplasty in three and duodenoscopic sphincterotomy in one, are described. All patients were diagnosed by endoscopic pancreatic sphincter manometry confirming the diagnosis of a hypertensive pancreatic sphincter. Hydrostatic balloon dilation of the pancreatic sphincter was successfully employed as a single therapeutic modality. It is likely that more widespread use of these techniques will lead to an increase in the reported incidence and to a nonsurgical treatment in a condition previously thought to be rare.

Endoscopic cholangiopancreatoplasty: hydrostatic balloon dilation in the bile duct and pancreas.

Specially designed catheters containing durable polyethylene balloons have been employed in the treatment of strictures of the bile duct and pancreas and the sphincter of Oddi during the performance of endoscopic retrograde cholangiopancreatography (ERCP). Twenty-four patients with strictures of the distal common bile duct and/or dysfunction of the sphincter of Oddi and six patients with proximal biliary strictures comprised the biliary group, while six patients with strictures of either the primary pancreatic duct or accessory systems made up the pancreatic group. No significant complications occurred following biliary dilation, while uncomplicated, mild pancreatitis was associated with pancreatic manipulation. The early results of hydrostatic dilation are encouraging, but larger series and longer term follow-ups are necessary before its efficacy can be determined.

Endoscopy retrograde cholangiography.

Since introduction of endoscopic cannulation of the ampulla of Vater, endoscopic retrograde cholangiopancreatography has become a widely used procedure for evaluating suspected biliary tract and pancreatic disease. ERCP is a somewhat sophisticated technique that can be successfully mastered by the trained endoscopist after a reasonable commitment of time and good training. The ability to cannulate the papilla of Vater under direct vision to facilitate the opacification of the ductular structures of the biliary tract and pancreas has influenced our current approach to biliary and pancreatic disease by providing an expedient diagnosis and thus specific management.

[Comparison of urease test (CLOtest) and histology in the diagnosis of Campylobacter pylori]. / Comparación entre la prueba de la ureasa (CLOtest) y la histología en el diagnóstico del Campylobacter pylori.

Campylobacter pylori has been implicated in the pathogenesis of peptic ulcer, non-ulcer dyspepsia and chronic gastritis. C. pylori produces large amounts of urease which has been used as a biochemical support to identify the microorganism. In this study, we described the use of a rapid urease test (CLOtest) to detect C. pylori. In 46 consecutive patients, biopsy of fundus and antrum were obtained for histology and CLOtest. All specimens showed chronic gastritis. In 22 patients (48%) C. pylori was identified either by histology or CLOtest. In 18 patients (39%) CLOtest was positive and in 16 patients (35%) histology was positive. In 12 patients (26%) C. pylori was identified by both tests. There was no difference in relation to the presence of C. pylori in fundus and antrum. However, in 2 patients (4%) C. pylori was positive in fundus and negative in antrum. In 9 patients (20%) C. pylori was positive in antrum and negative in fundus. CLOtest is a simple, sensitive and rapid test that enables the endoscopist to diagnose C. pylori infection in the endoscopy room.