Use of sedation for routine diagnostic upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy Survey of National Endoscopy Society Members.

BACKGROUND/AIMS: Sedation rates may vary among countries, depending on patients' and endoscopists' preferences. The aim of this survey was to investigate the rate of using premedication for routine diagnostic upper gastrointestinal (UGI) endoscopy in endoscopy societies, members of the European Society of Gastrointestinal Endoscopy (ESGE). METHODS: We evaluated a multiple-choice questionnaire which was e-mailed to representatives of national endoscopy societies, which are members of the ESGE. The questionnaire had 14 items referring to endoscopy practices in each country and the representatives' endoscopy units. RESULTS: The response rate was 76% (34/45). In 47% of the countries, less than 25% of patients undergo routine diagnostic UGI endoscopy with conscious sedation. In 62% of the responders' endoscopy units, patients are not asked their preference for sedation and do not sign a consent form (59%). Common sedatives in use are midazolam (82%), diazepam (38%) or propofol (47%). Monitoring equipment is not available 'in most of the endoscopy units' in 46% (13/28) of the countries. Though they were available in 91% of the national representatives' endoscopy units, they are rarely (21%) used to monitor unsedated routine diagnostic UGI endoscopy. CONCLUSIONS: In about 50% of ESGE-related countries, less than 25% of patients are sedated for routine diagnostic UGI endoscopy. Major issues to improve include availability of monitoring equipment and the use of a consent form.

Benign mesenchymal liver hamartoma in an adult male: a case report and review of the literature.

Mesenchymal hamartoma of the liver is an uncommon benign lesion seen almost exclusively in children younger than two years of age. The first case was reported in 1903, and until now fewer than 200 cases have been reported. A 38-year-old male complaining of dull subcostal pain lasting for almost 10 months was found on abdominal ultrasound to have a focal lesion of the liver. He was referred to our Unit where imaging procedures (ultrasound and computed tomography) revealed a solid lesion, 8 centimeters in diameter, located in the IVb and V segments of the liver. There were no clear margins between the lesion and the gallbladder wall. Alpha-fetoprotein and carcinoembryonic antigen were within normal limits and carbohydrate antigen 19-9 was minimally elevated. There was no evidence of metastatic disease. Ultrasound-guided biopsy of the lesion was done and pathology report of a biopsy specimen suggested that the tumor was probably a benign mesenchymal hamartoma. The patient underwent a formal bi-segmentectomy (IVb and V segments) with cholecystectomy. Definitive pathology report confirmed the diagnosis of a benign mesenchymal hamartoma.

[Drug therapy of hemorrhage in esophageal and gastric varices: role of vasoactive drugs]. / Medikamentna terapija krvarenja iz varikoziteta jednjaka i zeluca: mjesto i uloga vazoaktivnih lijekova.

Esophageal and gastric variceal bleeding is one of the most severe complications of portal hypertension and with high mortality. The aim of the therapy is to stop bleeding, replace the lost amount of blood and erythrocytes, treat coagulopathy, prevent rebleeding and improve liver function. Commonly accepted method to stop bleeding from varices is endoscopic hemostasis. Four vasoactive drugs, two natural peptides (vasopressin and somatostatin) and their analogues (terlipressin and octreotide) can control acute bleeding from gastric and esophageal varices. They lower portal pressure and the pressure in colateral circulation by vasoconstriction in splanchnic basin, and by inhibition the activity of endogenous vasodilatators. The high incidence of serious side-effects of vasopressin, even with nitroglycerin, has limited its application and decreased the use of this drug, with its abandonment in Europe. The vasopressin analogue, terlipressin, has a lower number of side-effects and is more effective in control of bleeding. Early terlipressin application at home, prior to hospital admission, diminishes mortality due to bleeding, thus attaching additional importance to this drug. Somatostatin, when applied as intravenous bolus injection, controls acute bleeding very efficiently and quickly. Five day somatostatin infusion after endoscopic hemostasis prevents rebleeding, with minimal side-effects. Octreotide is very efficient in long-term therapy of endocrine tumors due to its longer half-life, better hormone inhibition, and simple application compared to somatostatin. Like somatostatin, it can also control variceal bleeding. It appears that the long-term subcutaneous octreotide application prevents rebleeding and improves liver function, all of which yields a new dimension to its use.

Quantitative tissue carcinoembryonic antigen (T CEA) assay as a screening test for severe dysplasia in colorectal adenomas.

Relationship between the serum (S CEA) and the tissue (T CEA) carcinoembryonic antigen concentrations with regard to the degree of dysplasia in colorectal adenomas was investigated. Our study included 56 single or multiple colorectal adenomas in 46 patients. The measurements of T CEA concentrations were performed using the quantitative CEA-EIA method (Abbott) modified for wet tissue, obtained from heads of the adenomas. As a control point the mucosa near adenoma and the rectal mucosa were used. Our results suggest that the T CEA concentrations from the head of the adenoma demonstrate a highly significant difference between mild and severe dysplasia (P < 0.001), between mild dysplasia and invasive adenocarcinoma (P < 0.001) and a significant difference between mild and moderate dysplasia (P < 0.05). On the other hand, the S CEA concentrations corresponding to these cases showed no such differences. In conclusion, we suggest the quantitative measurement of T CEA concentrations as a screening test for severe dysplasia in colorectal adenomas.

Variations in the risk of gastrointestinal hemorrhage with non-steroidal anti-inflammatory drugs and localization of lesions.

The aim of this prospective study was to determine the effect of ulcerogenic drugs in patients with bleeding peptic ulcers and erosions with respect to their age and sex, ulcer history and additional risk factors such as family medical history, alcohol use, smoking, coffee consumption and stress. Of 367 patients with bleeding gastroduodenal lesions admitted during a period of 15 months, 88 (24%) had previously received ulcerogenic drugs. The most frequently taken drugs were aspirin (44.3%), piroxicam (12.3%) and ibuprofen (7.4%). Bleeding lesions were 1.4 times more frequently found in male users than in female users, and 2.1 times more often in male unusers. Males were more commonly receiving drugs than females (59.8%:40.2%), particularly those aged 34 to 54 years. Forty (45.5%) users had previously suffered from ulcer disease, 48 (54.5%) had negative history. There was no additional risk factor in 48%, whereas 58% of the users had one or more risk factors. It may be concluded with great certainty that NSAIDs caused hemorrhage in 13% of all admissions. Among users, a total of 119 different gastric and duodenal lesions were found. Gastric lesions were more common (54%) than duodenal lesions (46%) in males, while in females an inverse ratio was observed (41% of gastric and 59% of duodenal lesions). Among nonusers, gastric lesions were more frequent in females (M:F, 42%:48%), and duodenal lesions in males (M:F, 58%:52%). The number of lesions increased with age in both users and nonusers. Forty-three percent of all drug users had ulcers in the prepyloric region, 23% on the lesser curvature, and 14% at the posterior wall of the gastric corpus. Gastroduodenal erosions were seen in 11% of the males and 1% of the females. In nonusers, ulcers were found on the posterior wall of the corpus (27%), on the lesser curvature (25%) and in the prepyloric region (24%). Bleeding gastroduodenal erosions were found in 4% of the patients. Distribution of bleeding duodenal ulcers was similar in drug users and in nonusers, i.e. anterior wall (45%:44%), posterior wall (28%:27%), lower wall (16%:16%) and upper wall (3%:4%) of the duodenum. NSAIDs had no influence on the localization of duodenal ulcers. In this study, there was no death from ulcer disease with NSAID use. It may be concluded that NSAIDs are a common cause of damage to gastroduodenal mucosa. The risk of drug therapy should be balanced against the risk of the disease.

[Palliative treatment of malignant esophageal obstruction with a new endoscopically administered self-expanding nitinol stent: case report]. / Palijativni pristup malignoj opstrukciji jednjaka endoskopskom primjenom novog samosireceg (self-expanding) nitinolskog stenta; prikaz bolesnice.

The endoscopic methods of palliative treatment in malignant esophageal stenoses caused by neoplasm which have been performed so far unfortunately do not provide permanently satisfying results. The implantation of self-expanding stents with the purpose of removing malignant esophageal obstructions has recently become the most acceptable method of treatment. By using that method it is possible to reduce or even completely remove difficulties in swallowing. In that way a significant improvement in life quality of patients with inoperable esophageal cancer is possible. The various types of metal endoprostheses used for the palliative treatment of esophageal malignant stenoses are described in this paper. Here is also presented a case of nitinol stent implantation in a 50 year old woman suffering from esophageal cancer. This type of therapeutic treatment has been applied in Croatia for first time.

[Treatment of malignant bile duct obstruction with a metal stent. Case report]. / Rjesenje maligne opstrukcije zucovoda metalnim stentom. Prikaz slucaja.

In the case report we describe endoscopic implantation of endoprosthesis in the periampullar area in a 87 year old female patient with obstructive jaundice and cholangitis caused by pancreatic tumour. This is the first time that this procedure was successfully performed in Croatia.

Percutaneous pancreatography under ultrasonographic guidance.

PURPOSE: The aim of the study was to evaluate percutaneous pancreatography as an alternative method for pancreatic duct visualisation in patients with pancreatic disease. MATERIAL AND METHODS: In 21 patients with pancreatic disease and previously unsuccessful ERCP, puncture of the pancreatic duct was carried out under ultrasonographic guidance with an 0.7-mm Chiba needle, and contrast injection was made under fluoroscopic control in the pancreatic duct. RESULTS: The procedure was successful in 18 patients (86%). In 10 patients, chronic pancreatitis was found, and in 8 patients, pancreatic carcinoma. CONCLUSION: Percutaneous pancreatography is a good alternative method for visualisation of the pancreatic duct in patients with pancreatic disease and previously unsuccessful ERCP.

Comparison of injection sclerotherapy and laser photocoagulation for bleeding peptic ulcers.

BACKGROUND AND STUDY AIMS: The most widely used endoscopic procedures in the management of patients with bleeding peptic ulcer are at present sclerotherapy and thermal methods. In an attempt to assess the most effective method of achieving hemostasis, we compared injection sclerotherapy and laser photocoagulation in terms of the efficacy of initial hemostasis, rebleeding, need for surgery, mortality, and the appearance of the ulcer after the hemostatic procedure. PATIENTS AND METHODS: In this prospective, randomized trial, 160 patients were treated with injection sclerotherapy (1% polidocanol), and 155 patients with laser photocoagulation (Nd:YAG laser) in cases of Forrest I, Forrest IIa, and Forrest IIb hemorrhage. The bleeding activity was classified according to the modified Forrest criteria. Polidocanol injection and Nd:YAG laser photocoagulation were not preceded by epinephrine administration. RESULTS: There were no significant overall differences between the groups in the outcome in terms of definitive hemostasis, rebleeding, urgent surgery, and death (p = 0.487). In the case of the subgroup with Forrest I lesions, laser photocoagulation was more efficacious than sclerotherapy (p = 0.0078). In the Forrest IIa and Forrest IIb subgroups, the two methods were equally effective (p = 0.202 and 0.513 respectively). In the sclerotherapy patients, definitive initial hemostasis in Forrest IIa was achieved in 100%, whereas in the laser group this rate was 92%, with 28% of patients initially developing hemorrhage after one or two laser pulses. Ulcer healing was slower following sclerotherapy than after photocoagulation. CONCLUSION: Injection sclerotherapy and laser photocoagulation are equally effective in achieving definitive hemostasis in bleeding peptic ulcers. Laser photocoagulation is more efficacious in patients with active bleeding, whereas injection sclerotherapy is more effective in patients with a nonbleeding visible vessel.

[Hemostasis and treatment of stress hemorrhage in the upper gastrointestinal tract of trauma patients]. / Blutstillung und Behandlung von Stressblutungen im oberen gastrointestinalen Trakt bei Verwundeten.

Despite the use of H2-receptor antagonists for the prevention of stress lesions, 32 (9%) of the 354 wounded treated at the surgical intensive care units presented with upper gastrointestinal bleeding. 28 (87.5%) patients underwent endoscopic examination. The types of hemorrhage (capillary, venous and arterial bleeding) and the efficacy of hemostasis were analyzed. The bleeding ceased spontaneously in 17 (53.1%) patients, and 3 (9.4%) died in spite of all the endoscopic and surgical procedures undertaken.