[Clinical reflexions on a case of primary achalasia of the esophagus diagnosed late]. / Riflessioni cliniche su di un caso di acalasia primitiva dell'esofago tardivamente diagnosticata.

We describe an unusual case of achalasia. The patient, a 33-year-old woman, presented with a clinical history of esophageal disease verified by gastroscopy. The diagnosis of hysterical anorexia that had been made some years previously did not correspond with the nosological classifications (DSM III-R, DSM IV). This case underscores the importance of the correct use of clinical methodology, particularly when conclusive diagnosis is essential for successful treatment.

[Emergency endoscopy in children: experience of a digestive endoscopy department]. / Endoscopia in urgenza in età pediatrica: esperienza di un servizio di endoscopia digestiva.

Many changes and advances have been achieved in the last years, so that emergency endoscopy has now a definite role also in the diagnosis and treatment of diseases in childhood. In order to determinate main indications to endoscopic examination, and which are the most useful diagnostic and therapeutic measures that should be performed, we examined the records of 202 patients (aged 1 day-14 years) undergone emergency endoscopy from June 1979 to January 1990. Patients were referred to endoscopy because of foreign bodies or caustic ingestion, hematemesis, and in one patient a suspected intussusception. We didn't record any complication. Our study shows that emergency endoscopy has a definite role also in pediatric age and gives a diagnostic and therapeutic gain in the management of many diseases.

A new protector device for safe endoscopic removal of sharp gastroesophageal foreign bodies in infants.

The accidental ingestion of sharp foreign bodies into the upper-gastrointestinal tract is not uncommon in children. Endoscopic extraction of these objects poses technical difficulties, and a number of dangerous complications can occur. We present two cases of successful retrieval of large, sharp gastroesophageal foreign bodies in small children using a new, commercially available endoscopic end protector hood that prevents exposure of the esophageal and pharyngeal wall to injuries and laceration by the foreign body. This device is simple to use, versatile, and effective and advances the safe endoscopic removal of a variety of gastroesophageal foreign bodies in pediatric patients.

Endoscopic protector hood for safe removal of sharp-pointed gastroesophageal foreign bodies.

Endoscopic removal of sharp and pointed foreign bodies in the upper gastrointestinal tract still poses technical difficulties. Overtubes may be uncomfortable to the patients and only objects fitting within a lumen of about 11-15 mm can be removed. We present here our preliminary experience with a commercially available new endoscopic end protector hood having the unique characteristic of maintaining its bell portion inverted during the progression of the scope through the gut and flipping back to its original shape during withdrawal through the lower esophageal sphincter. This prevents exposure of the esophageal and pharyngeal wall to injuries from the edges of the foreign body. We used this device to remove nine large sharp or pointed gastroesophageal foreign bodies in six consecutive patients in whom conventional techniques were considered unsafe or not technically feasible owing to the size and shape of the objects. In all cases, removal was successful and easily performed without bowel damage. We believe that this device enhances the safe removal of a wide variety of potentially dangerous gastroesophageal foreign bodies.

Visual "disappearing phenomenon" can reliably predict the nonadenomatous nature of rectal and rectosigmoid diminutive polyps at endoscopy.

Previous studies have failed to differentiate adenomatous from nonadenomatous diminutive polyps according to their gross macroscopic features at endoscopy. We prospectively evaluated the prevalence, distribution, and predictive value of a recently described morphologic feature-the "disappearing phenomenon"-in diminutive polyps of the distal 20 cm of the large bowel by studying 218 polyps in 90 consecutive patients. Disappearance was graded as complete, incomplete, or absent. Overall, complete disappearance was noted in 93 (43.1%) polyps, with a significantly higher prevalence in the middle and lower rectum (p < .05) and among smaller, paler, and smooth-surface polyps (p < .001). Incomplete disappearance was detected in both nonadenomas (23.1%) and adenomas (15.8%), but, more importantly, complete disappearance occurred in none of the 19 observed adenomas compared with 93 of 199 nonadenomas. Multiple logistic regression analysis revealed that disappearance was the strongest predictor (p < .001) of nonadenomatous histology among considered morphologic criteria. When complete disappearance was used to predict histologic type of diminutive polyps, its sensitivity was 100% and its specificity was 46.7%. In conclusion, the disappearing phenomenon represents a reliable visual marker for identifying nonadenomatous rectal and rectosigmoidal diminutive polyps at endoscopy. Diminutive polyps that disappear completely upon insufflation are invariably nonadenomatous and should not require endoscopic biopsy or removal.

[Cholestasis caused by ulcerative Vater's papillitis in a child with AIDS]. / Cholestase secondaire à une papillite ulcérative de Vater chez un enfant atteint de SIDA.

A case of cholestasis induced by ulcerative papillitis in an 11 month-old boy with AIDS is described. Resolution of cholestasis has been achieved with medical therapy. The authors underline the necessity of repeated endoscopic follow-up to evaluate the risk of secondary papillary stenosis, a complication usually observed in adults.

Randomized placebo-controlled trial of oral liquid simethicone prior to upper gastrointestinal endoscopy.

It has been suggested that pre-procedural oral simethicone improves visibility in upper GI tract endoscopy. We examined three-hundred-thirty patients referred for upper endoscopy who were randomized and were required to swallow a placebo solution or one of three liquid simethicone solutions 15 min prior to the examination. These solutions contained 65 mg, 65 mg and 195 mg of drug dissolved in 90 ml, 30 ml and 90 ml of water, respectively. Patients treated with both dosages of simethicone revealed significantly less foam and bubbles in both the stomach and the duodenum compared to placebo. Only the 90 ml volume adequately cleared both locations. The reduction of examination time could be found both in patients with an intact stomach and in patients with or without gastric bile reflux, but was most striking in patients with previous gastric resection (examination time being reduced by almost 50% and the need of adjunctive lavage being reduced about 20 fold compared to placebo). In conclusion, pre-procedural oral simethicone should be routinely considered in patients with previous gastric resection. The utility of the drug is less evident in patients with normal gastric anatomy.

Oral isosorbide-5-mononitrate reduces the rebleeding rate during the course of injection sclerotherapy for esophageal varices.

A double-blind, multicenter trial was carried out to assess the effectiveness of isosorbide-5-mononitrate in preventing recurrent variceal hemorrhage during the course of endoscopic sclerotherapy. Seventy-six patients with their first bleeding episode from esophageal varices were randomly allocated, after initial control of hemorrhage, to groups receiving either 50 mg/day oral isosorbide-5-mononitrate retard (37 patients) or an identical placebo (39 patients) until variceal eradication. Sclerotherapy was performed at weekly intervals, and varices were intra- and para-variceally injected with 1% polidocanol until eradication. If rebleeding occurred, additional sclerotherapy was performed. Four (10.8%) patients rebled in the isosorbide group, compared with 15 (38.4%) in the placebo group (p = 0.01). The total number of rebleeding episodes was also significantly lower in the isosorbide group (5 versus 19, p = 0.043), whereas comparison between major versus minor rebleedings was not significant. The median transfusion requirement per bleeding episode was not significantly different in the two groups, although the cumulative number of blood units transfused was over threefold greater (22 versus 70) in the placebo group. Two (5.4%) deaths occurred among isosorbide-treated patients and nine (17.9%) among placebo patients (NS). The number of sclerotherapy sessions and the time required to obtain variceal eradication were also comparable in the two groups. Finally, the nitrovasodilator was well tolerated, requiring withdrawal for severe headache in only one patient. In conclusion, isosorbide-5-mononitrate reduces the rebleeding rate and the number of rebleeding episodes before variceal eradication in patients treated with sclerotherapy.