Myocardial ischemia during endoscopic retrograde cholangiopancreatography - A real problem?

AIM: The occurrence of silent myocardial ischemia during endoscopic retrograde cholangiopancreatography (ERCP) has been documented, but its clinical significance remains unknown. The aims of this study were to investigate the incidence and risk factors of myocardial ischemia during ERCP, to determine the presence or absence of permanent myocardial injury and to evaluate if deep sedation with propofol had a positive effect on myocardial ischemia during ERCP. METHODS: Ambulatory ST-segment monitoring from 30 minutes prior to 4 hours after ERCP was obtained on 50 patients. A deep sedation was performed with intravenous propofol administered by anesthesiologist. Changes in vital signs during ERCP, pre and postprocedural 12-lead ECG examination and cardiac enzymes were evaluated. RESULTS: Silent cardiac ischemia occurred only in one patient (2%) during ERCP. This 64-year-old patient did not develop hypoxemia, tachycardia or hypotension periods during the exam. None of the patients developed cardiac enzymes or postprocedural electrocardiographic changes. Thirty seven (74%) patients suffered rhythm changes. CONCLUSION: Although rhythm disturbances were common, silent myocardial ischemia during ERCP was rare (2%) and without clinical relevance. In prolonged or complex therapeutic procedures, like ERCP, deep sedation with propofol performed by trained personnel is associated with reduced cardiac complications.

Colonoscopies in Portuguese district hospitals: a multicentric transverse study.

OBJECTIVE: To characterise the colonoscopies performed in the Portuguese District Hospitals. METHODS: Transverse study conducted between 7 and 18 March 2005 amongst the 33 District Hospitals throughout Portugal. Data collected included the following: gender, age, geographical origin, ambulatory or hospitalised, routine or emergency, type of preparation, sedation practice (if any), informed consent, indication, extent of the visualisation of the colon and final result (endoscopic and histological). RESULTS: Thirty-one of the 33 District Hospitals (94%) sent the reports of colonoscopies and biopsies performed during the aforementioned period, resulting in 1245 colonoscopies. The majority of colonoscopies were ambulatory (80.7%); in 12 centres informed consent was obtained. The main indications were the following: polipectomy (20%), haematochezia (15%) and polyp follow-up (10%), whereas screening for colorectal cancer was the sixth most frequent indication. Sedation was administered in 24.5% of procedures. Colonoscopies were complete in 69.6% of cases. The main reasons for incomplete colonoscopies were poor bowel preparation, patient discomfort or technical difficulty. Colonoscopies were normal in 36% of cases; 40.3% had polyps, 16.4% had diverticulosis, 4.8% had colorectal cancer, 3.5% had inflammatory bowel disease and 1.1% had angiodisplasias. CONCLUSION: There was a high interest in participating in this study by Endoscopy Units in Portuguese District Hospitals. There is a low number of units using informed consent, which is mandatory by law, and this should be corrected. There is a need to increase sedation practice and to find better ways for preparing the colon, in order to achieve a higher percentage of complete colonoscopies and of polypectomies. The numbers of polyps detected and of colorectal cancers diagnosed confirm the importance of screening for colorectal cancer.

Acute necrotizing esophagitis: a large retrospective case series.

BACKGROUND AND STUDY AIMS: Acute necrotizing esophagitis is a rarely described entity. Its incidence has not yet been established, and its multifactorial etiology remains unknown. The aim of the present study was to establish the incidence, clinical presentation, endoscopic course, accompanying factors, and pathogenesis of the condition. PATIENTS AND METHODS: A retrospective analysis of clinical, laboratory, endoscopic and histological data and the clinical course in 29 patients with acute necrotizing esophagitis was carried out over a 5-year period. RESULTS: Acute necrotizing esophagitis was observed in 29 of 10 295 upper gastrointestinal endoscopies (0.28 %) carried out during the 5-year period. The average age of the patients was 75.24 years (range 40 - 91), and they were predominantly male. Eighty-three percent of the patients had comorbid conditions. In all cases, acute necrotizing esophagitis became evident with upper gastrointestinal bleeding, without hemodynamic stabilization in the majority of cases (75.9 %). The lesions predominantly affected the lower two-thirds of the esophagus (59 %), and there were coexisting abnormal endoscopic findings in 83 % of cases. Empirical supportive therapy, including oral nutritional rest, omeprazole, sucralfate (15 cases) and broad-spectrum antibiotics (7 cases) was provided. The condition resolved in all patients. Ten patients in the group died of other causes (coexisting illnesses). CONCLUSIONS: Acute necrotizing esophagitis was more commonly recognized than has previously been reported. It is a serious clinical entity that should be considered in the differential diagnosis of upper gastrointestinal bleeding, particularly in elderly patients. The prognosis depends more on the patient's advanced age and on comorbid illnesses than on the course of the esophageal lesions, which resolved in all patients in this series.