Effervescent agents in acute esophageal food impaction.

Acute esophageal food impaction (AEFI) occurs frequently. Few data are published describing the use of effervescent agents (EAs) for treatment of AEFI. We aimed to evaluate the effectiveness, cost, and safety of EAs in the treatment of AEFI. We retrospectively identified patients aged 18 years and older who were seen in the emergency department of 2 hospitals in 1 metropolitan area from January 1, 2011, through April 4, 2016, who had a clinical diagnosis of AEFI. We collected and analyzed data on outcomes and cost associated with the use of EAs, glucagon, and no pharmacologic therapy. During the study period, 239 patients with AEFI met the inclusion criteria. Of the 45 patients who received EA monotherapy, 25 (55.6%) responded successfully, compared with 11 of 62 (17.7%) who received glucagon monotherapy (P < .001) and 16 of 93 (17.2%) who had no therapy (P < .001). Ten of 39 patients (25.6%) who were given both glucagon and EA responded successfully. The other 177 patients had endoscopy, which was successful in all cases. Median hospitalization charges for patients who responded successfully to EA alone were $1,136, compared with $2,602 for responders to glucagon alone (P < .001) and $1,194 for those who cleared their bolus spontaneously (P < .001). All patients who received EA monotherapy had lower median hospitalization costs ($2,384) than all patients who received glucagon monotherapy ($9,289; P = .03) and all patients who received neither ($8,386; P = .02). Effervescent agents are a safe, effective, and cost-saving initial strategy in the treatment of acute esophageal food impaction.

Do recent reports about the adverse effects of proton pump inhibitors change providers' prescription practice?

Proton pump inhibitors (PPI) are utilized for a variety of indications, including treatment of gastroesophageal reflux disease, peptic ulcer disease, and prevention of gastrointestinal (GI) bleeding. Several studies have documented an increasing prevalence of inappropriate PPI use. Furthermore, recent media reports have highlighted new research data suggesting a possible association between chronic PPI use and several adverse medical outcomes, leading to frequent patient inquiries about these associations. Thus, providers face the challenge of counseling patients about the balance of risks and benefits related to PPI use. We aimed to explore providers' knowledge and attitudes toward reported adverse effects of PPI use and compare providers' prescription practices. A comprehensive, non-incentivized electronic survey was sent to all providers (residents, fellows, advanced practice providers, and consultants across 8 internal medicine specialties) at our tertiary academic medical center. The survey contained 21 questions covering provider demographics and responses to challenging clinical scenarios dealing with PPI use. Chi-square was used to compare responses from providers. The survey was distributed to 254 providers, of which 94 (24 GI and 70 non-GI) completed the survey (37% response rate). Among those 94 providers, 48 were consultants, 17 were advanced practice providers, and 29 were trainees. Non-GI providers included cardiology, pulmonary, endocrinology, family medicine, general internal medicine, hematology/oncology, and nephrology. Over half of the providers (51 [54%]) described their practice as outpatient setting, 29 (31%) providers defined their practice as a mixed setting (inpatient and outpatient), while 14 (15%) designated it as inpatient only. Nineteen (80%) GI providers and 48 (69%) non-GI providers discussed the risks and benefits with patients (P = 0.64). Fifteen (63%) GI providers and 33 (47%) non-GI providers indicated that recent reports changed their practice (P = 0.49). More GI providers (5 [21%]) lowered the dose of PPI compared with non-GI (1[1%]) (P = 0.004); 18 (26%) of non-GI and 3 (13%) of GI providers discontinued PPI and substituted it with a histamine 2 (H2) blocker (P = 0.29). A larger but nonsignificant percentage of trainees (8 [28%]) switched PPI to H2 blockers compared with consultants (8 [17%]; P = 0.39). Six (25%) of GI providers and 14 (20%) of non-GI providers were concerned about Clostridium difficile infection (P = 0.58). Twenty-four (34%) of the non-GI were worried about kidney diseases compared with 3 (13%) of the GI providers (P = 0.1). Ten (21%) consultants were concerned about risk of osteoporosis compared with 3 (10%) trainees (P = 0.38), while 8 (28%) trainees were worried about the risk of C. difficile infection compared with 10 (21%) consultants (P = 0.69). Most providers (85 [90%]) agreed that educational activities would be helpful to address these challenges. More GI providers lowered the dose of PPI compared with non-GI; non-GI providers were more likely to discontinue PPI and substitute it with an H2 blocker. Educating patients and providers about potential adverse effects of PPI is imperative.

Longitudinal outcomes of radiofrequency ablation versus surveillance endoscopy for Barrett's esophagus with low-grade dysplasia.

Radiofrequency ablation of Barrett's esophagus with low-grade dysplasia is recommended in recent American College of Gastroenterology guidelines, with endoscopic surveillance considered a reasonable alternative. Few studies have directly compared outcomes of radiofrequency ablation to surveillance and those that have are limited by short duration of follow-up. This study aims to compare the long-term effectiveness of radiofrequency ablation versus endoscopic surveillance in a large, longitudinal cohort of patients with Barrett's esophagus, and low-grade dysplasia.We conducted a retrospective analysis of patients with confirmed low-grade dysplasia at a single academic medical center from 1991 to 2014. Patients progressing to high-grade dysplasia or esophageal adenocarcinoma within one year of index LGD endoscopy were defined as missed dysplasia and excluded. Risk factors for progression were assessed via Cox proportional hazards model. Comparison of progression risk was conducted using a Kaplan-Meier analysis. Subset analyses were conducted to examine the effect of reintroducing early progressors and excluding patients diagnosed prior to the advent of ablative therapy. Of 173 total patients, 79 (45.7%) underwent radiofrequency ablation while 94 (54.3%) were untreated, with median follow up of 90 months. Seven (8.9%) patients progressed to high-grade dysplasia or adenocarcinoma despite ablation, compared with 14 (14.9%) undergoing surveillance (P = 0.44). This effect was preserved when patients diagnosed prior to the introduction of radiofrequency ablation were excluded (8.9% vs 13%, P = 0.68). Reintroduction of patients progressing within the first year of follow-up resulted in a trend toward significance for ablation versus surveillance (11.1% vs 23.8%, P = 0.053).In conclusion, progression to high-grade dysplasia or adenocarcinoma was not significantly reduced in the radiofrequency ablation cohort when compared to surveillance. Despite recent studies suggesting the superiority of radiofrequency ablation in reducing progression, diligent endoscopic surveillance may provide similar long-term outcomes.

Incidence of brain metastasis from esophageal cancer.

We investigated whether the incidence of brain metastasis (BM) from primary esophageal and esophagogastric cancer is increasing. A single-institution retrospective review identified 583 patients treated from January 1997 to January 2016 for stages I through IV cancer of the esophagus and esophagogastric junction (follow-up, ≥3 months). Collected data included demographic information, date and staging at primary diagnosis, histologic subtype, treatment regimen for primary lesion, date of BM diagnosis, presence or absence of central nervous system symptoms, presence or absence of extracranial disease, treatment regimen for intracranial lesions, and date of death. The overall cohort included 495 patients (85%) with adenocarcinoma and 82 (14%) with squamous cell carcinoma (492 [84%] were male; median age at diagnosis, 68 years [range: 26-90 years]). BM was identified in 22 patients (3.8%) (median latency after primary diagnosis, 11 months). Among patients with BM, the primary histology was adenocarcinoma in 21 and squamous cell carcinoma in 1 (P = 0.30). BM developed in 12 who were initially treated for locally advanced disease and in 10 stage IV patients who presented with distant metastases. Overall survival (OS) after BM diagnosis was 18% at 1 year (median, 4 months). No difference in OS after BM diagnosis was observed in patients initially treated for localized disease compared to patients who presented with stage IV disease; however, OS was superior for patients who initially had surgical resection compared to patients treated with whole brain radiotherapy or stereotactic radiosurgery alone (1-year OS, 67% vs. 0%; median OS, 13.5 vs. 3 months; P = 0.003). The incidence of BM is low in patients with esophageal cancer. Outcomes were poor overall for patients with BM, but patients who underwent neurosurgical resection had improved survival.

The clinical significance of hypercontractile peristalsis: comparison of high-resolution manometric features, demographics, symptom presentation, and response to therapy in patients with Jackhammer esophagus versus Nutcracker esophagus.

The Chicago Classification version 3.0 (CC v 3.0) defines hypercontractile peristalsis as Jackhammer esophagus (JE); Nutcracker esophagus (NE) is no longer recognized. Data regarding patient characteristics and treatment response for JE versus NE are limited. We aimed to compare demographic characteristics, high resolution manometry (HRM) features, clinical presentation, management strategies, and treatment outcomes in patients with JE versus NE. We performed a retrospective analysis of adult patients diagnosed with NE (CC v 2.0) or JE (CC v 3.0) by HRM from January 2012 to August 2015. Demographics, symptoms, treatments, and response to therapy (none or partial/complete) were ascertained by chart review, for statistical comparisons. In 45 patients with JE and 29 with NE, there was no significant difference in rate of dysphagia (73% and 59%) or chest pain (44% and 59%). Treatment data were available in 29 JE (smooth muscle relaxants in 4, pain modulators in 3, botulinum toxin injection (BTX) in 10, endoscopic dilation in 5, multimodal treatment in 7), and 20 NE patients (smooth muscle relaxants in 2, pain modulators in 2, (BTX) in 6, endoscopic dilation in 3, multimodal treatment in 7). Follow-up data on 26/29 JE and 20/20 NE patients showed similar treatment response (96.4% vs. 82.1%, p= 0.08) after mean follow-up of 11.2 and 11 months, respectively. There were no major differences for JE versus NE in demographics, symptoms, or type of and response to therapy. Larger prospective, controlled trials are needed to clarify the clinical significance and response to treatment in JE and NE.

Prevalence of buried Barrett's metaplasia in patients before and after radiofrequency ablation.

BACKGROUND AND STUDY AIM: Radiofrequency ablation (RFA) to treat Barrett's esophagus is increasingly accepted. Description of the etiology, natural history, and prevalence of buried Barrett's metaplasia (BBM) following RFA is limited, although BBM continues to pose a clinical dilemma. We aimed to assess the prevalence, characteristics, and eradication rate of BBM in patients with both dysplastic and nondysplastic Barrett's esophagus, treated with RFA and followed over time. PATIENTS AND METHODS: The presence of Barrett's esophagus, dysplasia, and BBM, before and after RFA, was assessed by two gastrointestinal pathologists in a retrospective chart review of patients who had undergone RFA at our center and had completed appropriate follow-up. RESULTS: We identified 112 patients with completed treatment and no further planned RFA. In 108, no residual Barrett's esophagus was seen after RFA; 4 patients with persistent Barrett's tissue underwent surgery. Regarding BBM, 17/112 patients (15.2%) had evidence of BBM during evaluation. In 12/17 (70.5%) BBM was found during the RFA treatment, with 8 having previously undergone non-RFA therapy and RFA for Barrett's esophagus and 4 having no previous intervention. In 5/17 (29.4%), BBM was seen only after RFA monotherapy. All 17 showed no evidence of BBM at final evaluation and were classified in the complete remission group (108/112). CONCLUSION: Both Barrett's esophagus and BBM were completely eradicated in all patients with long-term follow-up after RFA. Almost half of the patients with BBM had a prior history of non-RFA therapy for Barrett's esophagus compared with 26% the non-BBM cohort. All patients with previously identified Barrett's esophagus and BBM were completely cleared of disease at final follow-up.

The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy.

Failure of cecal intubation when using air insufflation during scheduled unsedated colonoscopy in veterans prompted a literature search for a less uncomfortable approach. Water-related maneuvers as "adjuncts" to air insufflation were identified as effective in minimizing discomfort, although medication requirement was not reduced and willingness to repeat unsedated colonoscopy was not addressed. These adjunct maneuvers were combined with turning the air pump off to avoid colon elongation during insertion. Warm water infusion in lieu of air insufflation was evaluated in observational studies. Subsequent refinements evolved into the water method - a combination of air exclusion by aspiration of residual air to minimize angulations at flexures and a dynamic process of water exchange to remove feces in order to clear the view and aid insertion. In subsequent randomized controlled trials, the water method significantly reduced medication requirement, increased the proportion of patients in whom complete unsedated colonoscopy could be achieved, reduced patient recovery time burdens (sedation on demand), decreased abdominal discomfort during and after colonoscopy, enhanced cecal intubation, and increased willingness to repeat the procedure (scheduled unsedated). Supervised education of trainees and self-learning by an experienced colonoscopist were feasible. Lessons learned in developing the water method for optimizing patient-centered outcomes are presented. These proof-of-principle observations merit further research assessment in diverse settings.

Effect of acid on duodenal blood flow and mucus secretion measured by reflectance spectrophotometry: a prospective, randomized-controlled study.

BACKGROUND: In animals, hydrochloric acid increases blood flow and mucus secretion in the duodenal mucosa. A significant correlation between index of haemoglobin oxygen saturation and mucosal blood flow, and between change in index of haemoglobin concentration and mucus thickness, respectively, has been demonstrated by reflectance spectrophotometry. AIM: To examine the effect of topical hydrochloric acid upon mucosal blood flow and mucus secretion in the human duodenum. METHODS: This prospective study of 120 patients undergoing routine upper endoscopy, examined the effect of topical 0.1 n hydrochloric acid or 0.9% saline on the duodenal bulb in a randomized, double-blind fashion. Duodenal mucosal index of haemoglobin oxygen saturation and index of haemoglobin concentration were measured by endoscopic reflectance spectrophotometry before and after hydrochloric acid or saline. RESULTS: Baseline index of haemoglobin oxygen saturation, calculated blood flow and index of haemoglobin concentration measurements were comparable between hydrochloric acid (n = 60) and saline (n = 60) treated groups. A history of current use of non-steroidal anti-inflammatory drug was associated with a significantly lower baseline index of haemoglobin oxygen saturation and calculated blood flow. Hydrochloric acid resulted in a significant increase in index of haemoglobin oxygen saturation and calculated blood flow, but a decrease in index of haemoglobin concentration, reflecting an increase in mucus thickness compared with saline. CONCLUSIONS: Our observations in humans confirm data in animal studies that topical exposure to hydrochloric acid induces an increase in duodenal mucosal blood flow and mucus secretion. Post hoc analysis of the data also revealed that attenuation of basal duodenal mucosal blood flow is associated with a history of current non-steroidal anti-inflammatory drug use. Endoscopic reflectance spectrophotometry appears to be adequate to assess factors that influence duodenal defence mechanisms of blood flow and mucus secretion in humans.

Short report: a non-metronidazole triple therapy for eradication of Helicobacter pylori infection--tetracycline, amoxicillin, bismuth.

Triple therapies using bismuth, metronidazole and tetracycline or amoxicillin were the first truly successful anti-H. pylori therapies. Metronidazole resistance has become an increasing problem that has severely limited the usefulness of the original triple therapy. Resistance to tetracycline or amoxicillin has not been reported and both are effective against H. pylori. We therefore tested a new triple therapy consisting of 500 mg tetracycline, 500 mg amoxicillin, and 2 tablets of bismuth subsalicylate each administered four times daily (with meals and at bedtime) for 14 days during treatment with ranitidine 300 mg daily. H. pylori eradication was defined as no evidence of H. pylori one or more months after stopping therapy. H. pylori status was evaluated by a combination of urea breath test and histology. Sixteen patients with H. pylori infection and active peptic ulcers were enrolled. The new triple therapy was successful in only 7 individuals (43%). Metronidazole appears to be critical for the effectiveness of the original triple therapy. An alternative to metronidazole will be required for a new successful triple therapy.

Diagnosis and treatment of gastroesophageal reflux disease in the elderly.

Gastroesophageal reflux disease poses special diagnostic and therapeutic challenges in the elderly. These patients may not report the classic symptoms of dysphagia, chest pain, and heartburn, and they are more likely to develop severe disease and complications such as esophageal ulceration and bleeding. Therapeutic options include lifestyle changes, medication, and surgery. Polypharmacy and changes in renal, hepatic, and gastrointestinal function can complicate treatment. Proton pump inhibitors can help optimize disease management. The most common primary presenting symptoms of GERD in the elderly are regurgitation, dysphagia, dyspepsia, vomiting, and noncardiac chest pain, rather than heartburn. Because the elderly commonly take multiple drugs for various comorbidities, drug interactions and treatment responses must be carefully assessed in this patient population. Nonpharmacologic measures may be helpful but often do not relieve nighttime GERD symptoms.

Vinegar as a disarming agent to prevent further discharge of the nematocysts of the stinging hydromedusa Olindias sambaquiensis.

Olindias sambaquiensis, known as agua viva, is an endemic hydromedusa that is distributed from latitude 23 degrees to 42 degrees south in the southwestern Atlantic Ocean and is known to cause severe stings. This is the first report of the use of vinegar in disarming O sambaquiensis nematocysts and includes preliminary observations on its use in managing the stings of hydromedusae.

Environment and virulence factors of Vibrio cholerae strains isolated in Argentina.

AIMS: To determine the presence of Vibrio cholerae in different areas of Argentina in three sample types, to determine the composition of planktonic communities in areas at which this pathogen was detected and to characterize the virulence properties and antimicrobial resistance of the recovered environmental isolates. METHODS AND RESULTS: Water and plankton samples were collected in marine, brackish and freshwater environments. Vibrio cholerae non-O1, non-O139 was isolated in 36.1% of the samples analysed. The micro-organism was detected in freshwater but not in marine or brackish samples. No relationship was found between isolation of V. cholerae and presence of any species of plankton. All the isolates presented very similar virulence profiles by PCR, lacking ctxA and tcpA El Tor and containing hlyA (98.7%), rtxA (99.0%), toxR (98.7%) and stn-sto (1.9%). Resistance to ampicillin was found in both Tucumán (21%) and Buenos Aires isolates (45%). CONCLUSIONS: We identified two geographic areas in Argentina where V. cholerae was present: freshwaters of the rivers from Tucumán and the Río de la Plata. SIGNIFICANCE AND IMPACT OF THE STUDY: The identification of V. cholerae strains in the environment, carrying both virulence factors and resistance to antimicrobial agents, highlight the need for a continuous and active surveillance of this pathogen.

Treatment of intractable hiccup with baclofen: results of a double-blind randomized, controlled, cross-over study.

Four patients with intractable hiccup were treated in a double-blind, randomized, placebo, cross-over study with an analogue of gamma-aminobutyric acid, Baclofen. There was a consistent and statistically significant (p = 0.03) improvement in hiccup severity with Baclofen, both subjectively (p = 0.03) and by hiccup-free periods (p = 0.003). The actual frequency of hiccup was not significantly altered by the medication. We propose that the mechanical aspects of hiccup are reduced by Baclofen, leading to a perceptual blockage and a decrease in the reflex severity induced by the gamma-aminobutyric acid analogue. We conclude that this medication may be useful for the treatment of intractable hiccup.

Accuracy in the diagnosis of short-segment Barrett's esophagus: the role of endoscopic experience.

BACKGROUND: The diagnosis of Barrett's esophagus is based on histologic demonstration of specialized intestinal metaplasia. Experience may be important in the endoscopic recognition of Barrett's esophagus, including in regard to appropriate procurement of biopsy specimens. The aim of this study was to assess factors that may influence accuracy in the diagnosis of short-segment Barrett's esophagus (SSB). METHODS: Endoscopy reports pertaining to procedures performed over a 1-year period that included esophageal biopsies because of suspected intestinal metaplasia were reviewed. Barrett's epithelium involving less than 2 cm of the distal esophagus was considered SSB; greater than 2 cm was considered long-segment (LSB). Endoscopists were regarded as "more experienced" if they had completed training more than 5 years earlier and "less experienced" if the time elapsed since the completion of training was less than 5 years. RESULTS: More and less experienced endoscopists both obtained esophageal biopsy specimens because of suspected Barrett's esophagus at the same rate (14%). Length of suspected Barrett's epithelium was not predicted by symptoms or demographic data. Endoscopically, patients with SSB had significantly fewer (64.2% vs. 90.8%) and smaller (2.9 +/- 0.1 vs. 3.5 +/- 0.2 cm) hiatal hernias compared with those with LSB (p < 0.05). Suspected SSB was histologically confirmed in 38.4% (True SSB), whereas LSB was confirmed in 75% (True SSB) (p < 0.05). More experienced endoscopists were significantly more likely to obtain histologic confirmation of SSB than less experienced endoscopists (48.6% vs. 29.5%; p = 0.02, nominal significance from univariate hypothesis testing; correction for multiple testing of data removed significance at the p < 0.05 level; OR = 2.26). CONCLUSION: With greater experience, an endoscopist is more likely to diagnose SSB. This may be due to more accurate procurement of adequate tissue samples, which thereby results in a greater yield of histopathologic diagnoses.

The utilization of flexible sigmoidoscopy by family practitioners after residency training.

BACKGROUND: Flexible sigmoidoscopy is routinely performed by family practice physicians, most of whom receive training in postgraduate education programs. The aim of this study was to assess the utilization of flexible sigmoidoscopy by family practitioners who received training during residency. METHODS: Family practitioners who underwent training in flexible sigmoidoscopy during their residency were contacted by phone or mail and polled regarding their current use of flexible sigmoidoscopy and assessment of their previous training. RESULTS: Forty-two graduates were contacted; 76% were certified (according to our predefined criteria) during training and 74% were currently performing flexible sigmoidoscopy. Of those who were certified, 87% were currently using flexible sigmoidoscopy compared with 45% of those who did not receive certification (p = 0.02). Training during the last year of residency was more likely to be associated with current use of flexible sigmoidoscopy than earlier training (69% vs. 30%, p = 0.03). Certification was associated with more procedures during training (24.3 +/- 1.7 vs. 16.6 +/- 3.1, p < 0.05). Current users performed a mean of 4.3 +/- 0.75 procedures/month; most reached 40 cm in depth of insertion and completed the procedure in 17.2 +/- 1.2 minutes. Of patients undergoing flexible sigmoidoscopy, 13% were ultimately referred for colonoscopy. Most practitioners considered their training useful and only 9.6% had obtained additional training outside residency. CONCLUSIONS: Most family practitioners certified in flexible sigmoidoscopy during residency performed the procedure in their practices. Depth of insertion and time for completion of the procedure seem to be adequate.

A prospective evaluation of the endoscopic spectrum of overtube-related esophageal mucosal injury.

BACKGROUND: Placement of an overtube is required for endoscopic variceal ligation. The spectrum of overtube-related esophageal mucosal injury is unknown. We made a prospective comparison of two types of overtubes and a determination of the frequency, severity, and risk factors for overtube-related injury. METHODS: Two overtubes (60F, 20 cm, "new" overtube; and 60F, 25 cm, "old" overtube) were used and placed using the bougie-assisted technique. Mucosal integrity was documented before and after variceal ligation. Overtube contact time, bands number, setting (emergent versus elective), type of overtube, degree of coagulopathy, and development of symptoms after variceal ligation were recorded. RESULTS: Fifty sessions in 29 patients were analyzed; 24% of sessions were emergent. The old overtube was used in 24 sessions and the new in 26. Mucosal injury occurred in 72% of sessions. Mean overtube contact time was 11.58 +/- 0.97 minutes, the mean number of bands placed per session was 6.4 +/- 0.4, and the mean international normalized ratio was 1.47 +/- 0.06. No risk factors correlated with mucosal injury except for the old overtube, which was associated with tears (p = 0.02). CONCLUSIONS: Mucosal injury related to the overtube is frequent but clinically unimportant. Because mucosal tears occurred significantly more often with the old overtube, we suggest that its use should be avoided.

All lactase preparations are not the same: results of a prospective, randomized, placebo-controlled trial.

OBJECTIVE: To compare the efficacy of three commercially available oral lactase preparations in adults with lactose intolerance. METHODS: Design--Prospective, randomized, placebo-controlled trial. Setting--Outpatient study in a General Clinical Research Center. Subjects--Ten lactose-intolerant healthy volunteers were challenged with ice cream containing 18 g of lactose. Lactase or placebo was given immediately prior to challenge. Measurements--Symptoms and breath hydrogen excretion were recorded for 3 h following lactose challenge. RESULTS: The three products differed in their abilities to influence symptoms and breath hydrogen excretion. Only Lactaid reduced the breath hydrogen excretion with lactose (mean peak, area under the curve and cumulative breath hydrogen excretion) (p < 0.05). Lactrase and Dairy Ease influenced symptoms: Lactrase reduced pain, bloating and total symptomatic scores (p < 0.05), whereas Dairy Ease only reduced pain (p < 0.05). Lactaid administration did not reduce symptoms. CONCLUSION: In lactose-intolerant subjects, the available lactase preparations differ in their ability to improve both breath hydrogen excretion and symptoms. Lactrase may be the product of choice for achieving symptomatic improvement.

The short- and long-term efficacy of empirical esophageal dilation in patients with nonobstructive dysphagia: a prospective, randomized study.

OBJECTIVE: The efficacy of empirical esophageal dilation for nonobstructive dysphagia (NOD) is unknown. Our aim was to assess the efficacy and safety of empirical dilation with a large bougie in patients with NOD. METHODS: Patients with NOD (normal barium swallow, free passage of a 13-mm barium pill, and normal esophagogastroduodenoscopy) were randomized to dilation with either a 50-Fr (Group A) or 26-Fr (Group B) Maloney dilator. Before dilation, the dysphagia (DyspSC) and diet (DietSc) scores were recorded and an esophageal manometry performed. Both scores were reassessed at 1, 3, 7, and 14 days after dilation. Success was defined at day 14 as an improvement in the DietSc of at least 25% from baseline, or a DyspSc of < or =3. Nonresponders were crossed-over to the alternate dilator and restudied. RESULTS: Twenty-three patients (58.7+/-1.9 yr) were enrolled: 13 in Group A and 10 in Group B. Both groups were matched for age, baseline DyspSc (4.2+/-0.6 vs 3.8+/-0.5), baseline DietSc (13.3+/-1.7 vs 12.0+/-1.9), and manometric findings. A nonspecific motility disorder was seen in 43.4% patients. Group A had an initial response rate significantly greater (84.6%) than Group B (40%) (p = 0.03; odds ratio [OR] = 8.25). The DyspSc and DietSc were better than baseline with both dilators, but only the DietSc improved significantly in patients dilated with the 50-Fr dilator (5.3+/-1.9 vs 12.3+/-1.4; p = 0.004). At 2 yr, 80% of the patients responding to the 50-Fr Maloney had a sustained response. CONCLUSION: Empirical dilation with a large (50-Fr) bougie is safe, effective, and long-lasting in improving nonobstructive dysphagia.

Endoscopic stent placement for internal and external pancreatic fistulas.

Stents have been effectively used for various pancreatic conditions. Pancreatic fistulas, however, have traditionally been considered a surgical disease, and if the fistula does not respond to conservative measures, an operation is usually performed. Stents were placed endoscopically in five consecutive patients who presented with pancreatic fistulas that did not respond to conservative management. Fistulas resolved in all patients after endoscopic stent placement, and after 14-30 months of follow-up, none has recurred. The cases comprise two patients with pancreaticocutaneous fistula and one each with pancreaticopleural, pancreaticoperitoneal, and pancreaticocholedochal fistula. The need for an operation can be obviated in many patients with internal and external pancreatic fistulas.