Detection of tissue injury after extracorporeal shockwave lithotripsy of gallstones.

We evaluated seven patients undergoing gallstone lithotripsy for evidence of hepatic or renal trauma after each of 10 lithotripsy treatments. Postlithotripsy magnetic resonance imaging (MRI) and sonography showed no evidence of hepatic or renal injury as compared with baseline studies. Four treatments resulted in sonographic evidence of gaseous hepatic microbubbles (analogous to "the bends") due to cavitation effects of the shockwaves. Three of these four treatments produced serum glutamicoxaloacetic transaminase and -pyruvic transaminase elevation. One patient had microscopic hematuria. Minimal tissue damage results from gallstone lithotripsy. MRI and ultrasound, performed after lithotripsy, appear to be less sensitive than transaminasemia in detecting this low-grade injury.

Limited benefit of atropine as premedication for colonoscopy.

A prospective double-blind trial was performed comparing atropine (0.5 mg) by slow intravenous administration to placebo as premedication for colonoscopy, to assess the possible beneficial effects of this vagolytic agent on the performance and safety of the procedure. A total of 77 patients was randomly assigned to receive atropine (38 patients) or placebo (39 patients) before colonoscopy in conjunction with our standard initial medications for conscious sedation (meperidine, 0.4 mg/kg and midazolam, 0.03 mg/kg). Total procedure time was 31 min for the atropine group and 35 min for the placebo group (p greater than 0.05), and there was no overall difference in the total amount of intra-procedural medications required. No statistically significant differences were observed relative to the number or severity of vagal episodes, and neither the endoscopist nor the patients noted any differences in the ease or tolerance of the procedure (p greater than 0.05). Although these results fail to demonstrate a significant benefit of atropine when given routinely as premedication for colonoscopy, this study does not rule out the potential usefulness of atropine in counteracting vagal episodes when they occur.

Diltiazem therapy for symptoms associated with nutcracker esophagus.

UNLABELLED: A randomized double-blind, cross-over prospective trial in 22 patients was designed to evaluate possible effect of an oral calcium channel blocker, diltiazem, on symptoms of chest pain and/or dysphagia in patients with nutcracker esophagus. We studied 22 consecutive patients referred to an esophageal diagnostic center for evaluation of noncardiac chest pain or dysphagia having high amplitude esophageal contractions, 14 of whom completed the study. Diltiazem (60-90 mg qid) was compared with placebo, each being administered for 8 wk. Patients were evaluated with esophageal motility pre- and posttreatment periods and with regular symptom assessment throughout each 8-wk treatment. Active diltiazem therapy resulted in significantly lower (p less than 0.05) mean distal esophageal peristaltic pressure (128 +/- 20 mm Hg; +/- SE) than placebo (158 +/- 16 mm Hg). Mean chest pains scores were significantly (p less than 0.05) lower with diltiazem therapy than with placebo. Only nine of the 14 patients fulfilled presently acceptable criteria for diagnosing nutcracker esophagus, and the diltiazem effect was similar, although not significant, because of the smaller sample. CONCLUSIONS: In this preliminary study involving 14 patients, the oral calcium channel blocker, diltiazem, appeared to improve noncardiac chest pain associated with strong esophageal contraction, the nutcracker esophagus. These improved symptoms were associated with significant decreases in contraction pressure.

Utility of upper endoscopy in the evaluation of noncardiac chest pain.

The diagnostic yield of esophagogastroduodenoscopy, esophageal manometry, and Bernstein testing was assessed in 100 consecutive patients being evaluated for non-cardiac chest pain. Manometric studies revealed the nutcracker esophagus in 21 patients; non-specific esophageal motility disorders in 19 patients; a hypertensive lower esophageal sphincter in 4 patients; diffuse esophageal spasm in 2 patients; and normal motility in 54 patients. Endoscopy was normal in 38 patients; but revealed grades II to IV esophagitis in 24 patients; gastritis and/or duodenitis in 18 patients; a sliding hiatal hernia without evidence of esophagitis in 14 patients; and gastric or duodenal ulcers in 6 patients. Twenty-five individuals were found to have normal manometric studies in combination with a negative Bernstein test. Among these 25 patients, however, 7 patients had esophagitis (grade II or higher); 6 patients had gastritis and/or duodenitis; five patients had a sliding hiatal hernia without esophagitis; 1 patient had peptic ulcer disease; and only 6 patients had a normal endoscopic exam. Our results indicate that endoscopy can identify a significant number of patients with acid-peptic disease who present with non-cardiac chest pain, that would not have been otherwise diagnosed by esophageal manometry or Bernstein testing alone or in combination.

Abnormal cardiac sensitivity in patients with chest pain and normal coronary arteries.

The causes of chest pain in patients found to have angiographically normal coronary arteries during cardiac catheterization remain controversial. Cardiac sensitivity to catheter manipulation, pacing at various stimulus intensities and intracoronary injection of contrast medium was examined in several groups of patients who underwent cardiac catheterization. Right heart (especially right ventricular) catheter manipulation and pacing and intracoronary contrast medium provoked chest pain typical of that previously experienced in 29 (81%) of 36 patients with chest pain and angiographically normal coronary arteries and 15 (46%) of 33 symptomatic patients with hypertrophic cardiomyopathy. In contrast, only 2 (6%) of 33 symptomatic patients with coronary artery disease experienced their typical chest pain with these sensitivity tests (p less than 0.001). None of 10 patients with valvular heart disease but without a chest pain syndrome experienced any sensation with these tests. Cutaneous pain threshold testing demonstrated that patients with chest pain and normal coronary arteries had a higher pain threshold to thermal stimulation compared with patients who had coronary artery disease or hypertrophic cardiomyopathy. No relation existed between cardiac sensitivity and cutaneous sensitivity testing. Thus, patients who have chest pain despite angiographically normal coronary arteries may have abnormal cardiac sensitivity to a variety of stimuli. This increased sensitivity may be of causal importance to their chest pain syndrome or may contribute to their perception of ischemia-induced pain. The same phenomenon was also commonly seen in symptomatic patients with hypertrophic cardiomyopathy. Whether this phenomenon represents abnormal activation of pain receptors within the heart or abnormal processing of visceral afferent neural impulses in the peripheral or central nervous system is unknown.

Cavitation effects during lithotripsy. Part II. Clinical observations.

Cavitation effects during biliary lithotripsy can produce sonographically visible microbubbles. The relationship between microbubble formation and clinical outcome of gallstone lithotripsy performed with a commercial lithotriptor was studied in 50 treatments in 29 patients. Microbubble formation in bile was a useful predictor of successful stone fragmentation in 31 of 34 treatments. Microbubble formation in the liver correlated with transient hepatocellular damage (as indicated by a twofold rise in serum transaminase levels) immediately after seven of 10 treatments. Advancing the focal volume of the lithotroptor deeper into the patient (placing the stone at the proximal point of the focal zone) may be a useful strategy for reducing hepatic cavitation effects, which appear to be responsible for temporary hepatocellular damage.

A prospective study of the prevalence of colonic neoplasms in asymptomatic patients with an age-related risk.

This study was designed to determine the prevalence of colorectal neoplasia in healthy, asymptomatic adults with an age-related risk for colorectal neoplasia. Ninety patients were studied with air contrast barium enema and colonoscopy. The study population included 61 males and 21 females, with an age range of 51-82 yr (65 +/- 2 yr). Adenomatous polyps were found in 27% of males and 14% of females or 24% of patients overall. Sixty-six percent of these neoplasms were above the rectosigmoid junction and the mean size of the polyps was 6.5 +/- 1.2 mm. In two patients, carcinoma was discovered. A linear association between age and the prevalence of colonic neoplasia was not demonstrated. This study demonstrates a relatively high prevalence of colonic neoplasia in patients with an age-related risk.

Intraesophageal balloon distention versus drug provocation in the evaluation of noncardiac chest pain.

Intraesophageal balloon distention (IEBD) has been advocated as an effective provocative test for the evaluation of chest pain and dysphagia. The normal esophageal response to intraesophageal balloon distention is to generate a sustained contraction proximal to the balloon while showing a distinctive absence of activity distal to the balloon. We evaluated intraesophageal balloon distention in 62 patients with noncardiac chest pain and compared the diagnostic results to those obtained by using a combination of acid infusion, edrophonium (80 micrograms/kg iv) and bethanechol (80 micrograms/kg sq). These 62 patients were also compared with 10 normal volunteers who underwent intraesophageal balloon distention. Abnormal distal manometric activity consistent with spasm and was seen in 38/62 (61%) patients. Distal manometric activity was not seen in any normal volunteer. Diagnostic results (symptom reproduction with manometric changes but without EKG changes) were seen in 26/62 (42%) patients, but in nine of the 62 (14%) patients with combined drug provocation (p less than 0.05). Intraesophageal balloon distention is superior to a combination of provocative drugs in evaluating noncardiac chest pain symptoms. The presence of abnormal manometric activity distal to the balloon may represent regulation of esophageal motility.

Relationship between stone motion, targeting, and fragmentation during experimental biliary lithotripsy.

In vitro experiments in an anthropomorphic phantom were performed to clarify the relationship between stone motion, targeting, and fragmentation. Stone motion was minimized by pinning the stone against the dependent wall of a mock gallbladder cavity during shock wave treatment. Fragmentation was most effective (probably due to increased cavitation effects) when the shock wave traversed fluid at the point of its impact with a stone. The results suggest that treatment with the patient in the supine or oblique position may produce a better outcome than treatment in the prone position. Buoyant stones exhibited the greatest motion, which was often to-and-fro in nature. Although restricting the size of the mock gallbladder cavity reduced stone motion, maintaining a 1-cm fluid path was beneficial for achieving optimal pulverization.

Coronary flow reserve, esophageal motility, and chest pain in patients with angiographically normal coronary arteries.

PURPOSE AND METHODS: To ascertain the relative prevalence of abnormalities of coronary flow reserve and esophageal function in patients with chest pain despite angiographically normal coronary arteries, 87 patients underwent invasive study of coronary flow reserve and, during the same week, esophageal testing. RESULTS: Sixty-three of the 87 patients (72%) demonstrated abnormalities of coronary flow reserve, as evidenced by an increase in coronary resistance during the stress of rapid atrial pacing after administration of ergonovine 0.15 mg intravenously (1.33 +/- 0.36 mm Hg.minute/mL), compared with pacing at the same heart rate before ergonovine administration (1.10 +/- 0.33 mm Hg.minute/mL). This higher coronary vascular resistance occurred in the absence of significant epicardial coronary artery luminal narrowing. Fifty-seven of these 63 patients (90%) with a coronary vasoconstrictor response to ergonovine described their typical chest pain during pacing stress, compared with only six of 24 patients (25%) who demonstrated no coronary flow abnormality (p less than 0.001). After administration of dipyridamole 0.5 to 0.75 mg/kg intravenously to 65 patients, the 48 patients with ergonovine-induced vasoconstriction had a significantly higher minimum coronary resistance, compared with the 17 patients without a coronary vasoconstrictor response to ergonovine (0.65 +/- 0.21 versus 0.47 +/- 0.13 mm Hg.minute/mL, p less than 0.03). Twenty of 87 patients (23%) had abnormal esophageal motility [nutcracker esophagus (11), nonspecific motility disorder (seven), and diffuse esophageal spasm (two)], including 16 of the 63 patients (25%) with abnormal coronary flow reserve. Twenty-four (28%) patients experienced their typical chest pain during motility testing, but only five of these patients met criteria for abnormal esophageal motility. Nine of 75 patients tested (12%) had their typical chest pain during Bernstein testing, and 18 of 38 patients (47%) tested had their typical chest pain provoked by intraesophageal balloon distention. CONCLUSIONS: Seventy-one of 87 patients (82%) with anginal-like chest pain and normal epicardial vessels in our series had a disorder of either coronary flow reserve, esophageal motility, and/or reproduction of typical chest pain during acid infusion. Of interest, chest pain was commonly encountered during cardiac and esophageal testing (85% of patients), regardless of the ability to demonstrate an abnormality of coronary flow reserve or abnormal esophageal function. This suggests that pain experienced by these patients may be a consequence of myocardial ischemia, esophageal dysfunction, abnormal visceral nociception, or a combination of any or all of these entities.

Intraesophageal balloon distention in the manometric evaluation of chest pain.

Drug provocation is routinely used during esophageal manometry in the evaluation of chest pain of presumed esophageal origin. As significant side effects have been associated with the use of drugs in provocation, and these provocative tests are inadequately sensitive to exclude esophageal etiology as the cause of chest pain, alternative provocative tests have been sought. Intraesophageal balloon distention (IEBD) has recently been reintroduced as a method of pain provocation in the manometric evaluation of chest pain. IEBD produces pain on distention which resolves immediately on deflation. To evaluate graded IEBD as an effective and safe method of pain provocation, 66 consecutive patients presenting with chest pain and 10 asymptomatic volunteers were studied. We conclude that balloon distention is an effective and safe method of pain provocation and can easily be performed in conjunction with standard esophageal manometry.

Prospective evaluation of high-dose bethanechol in investigation of esophageal chest pain.

We compared the value of bethanechol 80 micrograms/kg subcutaneously, acid infusion with a 0.1 normal hydrochloric acid, and edrophonium 80 micrograms/kg intravenously as provocative agents to reproduce chest pain and manometric alterations in 72 patients with noncardiac chest pain. No patient developed typical chest pain and manometric alteration with acid infusion, while five (6.9%) patients developed these changes with edrophonium and four (5.6%) with bethanechol. Only one patient developed diagnostic changes exclusively with bethanechol. All patients tested with bethanechol developed some degree of local pain or significant cholinergic symptoms, with two patients requiring atropine for relief. Side effects from edrophonium were infrequent (28% of patients tested) and did not require atropine administration. We conclude that, using the parameters of typical chest pain and the development of manometric alterations as proof of the esophageal origin of chest pain, bethanechol at 80 micrograms/kg adds little information beyond that obtainable with edrophonium. Further, the high incidence of bethanechol-related side effects at 80 micrograms/kg suggests that this dose should not be generally recommended.

Manometric responses to balloon distention in patients with nonobstructive dysphagia.

The manometric responses to graded intraesophageal balloon distention were studied in 30 patients with symptoms of intermittent dysphagia but without evidence of structural narrowing on barium swallow or endoscopy, or both. These studies were compared with those performed in 10 normal volunteers. Using a manometric catheter with a balloon of reproducible dimension, balloon distention produced a sustained pressure proximal to the distended esophageal balloon in 28 of 30 (93%) patients and 9 of 10 (90%) normal volunteers. Patients with dysphagia had the reproduction of their characteristic symptom during balloon distention in 23 of 30 (76%) cases. Atypical symptoms not characteristic of the patients' usual dysphagia developed in the other 4 patients with dysphagia and in all controls. There were no electrocardiographic changes during balloon distention and symptoms were immediately reversible with balloon deflation. Repeated simultaneous contractions consistent with spasm distal to the distending esophageal balloon occurred in 21 of 30 (70%) patients with dysphagia but in no normal volunteers (p less than 0.05). Dysphagia reproduction was associated with the finding of repeated simultaneous contractions distal to the intraesophageal balloon being found in 20 of 30 (66%) patients (p less than 0.05). Distal activity during balloon distention of the esophagus is associated with dysphagia reproduction in a significant number of patients without any other explanation for their symptom. The development of distal spasm in patients with intermittent dysphagia suggests an abnormality of neural control that may be important in the pathophysiology of dysphagia in these patients.

A marked guide wire facilitates esophageal dilatation.

Esophageal dilatation by endoscopists is a commonly performed procedure. The introduction of tapered polyvinyl dilators by Savary has made the procedure even more popular. In the United States, esophageal dilatation with guide wires has been traditionally performed with fluoroscopy. By using a marked guide wire and by adhering to specific safety guidelines, the passage of the guide wire can be precise, even without fluoroscopy, and radiographic definition is not always required. This study describes the new guide wire and the technique.

Pulmonary disease in progressive systemic sclerosis. A complication of gastroesophageal reflux and occult aspiration?

Thirteen patients with progressive systemic sclerosis were studied to evaluate the possible role of gastroesophageal reflux as a contributing pathogenic factor in the pulmonary disease of the patients. The evaluation of all patients included fiberoptic esophagogastroduodenoscopy with biopsies of the esophagus, otolaryngologic evaluation, technetium Tc 99m sulfur colloid aspiration scan, pulmonary function testing, including the diffusing capacity for carbon monoxide (DLCO) test, and 24-hour intraesophageal pH monitoring with probes placed 5 and 15 cm above the lower esophageal sphincter. Eleven patients had microscopic and macroscopic evidence of proximal esophagitis, 12 patients had laryngeal changes suggestive of aspiration, and 12 patients had abnormal DLCO values. Using multiple regression analysis, the degree of DLCO impairment correlated with the proximal and distal reflux episodes and scores recorded by pH monitoring. There was direct and indirect evidence for proximal gastroesophageal reflux and aspiration in the majority of patients, and a distinct correlation between the severity of reflux and the severity of pulmonary disease. Aggressive antireflux therapy may be helpful in reducing the pulmonary damage due to aspiration in these patients.

Hyperplastic colonic polyps as a marker for adenomatous colonic polyps.

Hyperplastic colonic polyps are generally regarded as being of little or no clinical consequence. Recently, however, hyperplastic polyps have been found to share numerous functional similarities with colorectal carcinoma. To determine whether the presence of an isolated left-sided colonic hyperplastic (metaplastic) polyp could serve as a marker for more proximal synchronous adenomatous colonic polyps, we retrospectively analyzed all consecutive colonoscopic polypectomies performed over an 18-month period at two medical centers. It is the policy at both institutions to remove or biopsy all polyps, regardless of size. Indications for colonoscopy included known or previous colonic polyps or carcinoma, hemoccult positive stool, lower gastrointestinal bleeding, iron deficiency anemia, abnormal barium enema, inflammatory bowel disease, abdominal pain, and family history of colon cancer. The location of adenomatous polyps and hyperplastic polyps was recorded and compared. One hundred sixty-three of 845 consecutive patients (19.3%) had at least one colonic polyp. The prevalence of adenomatous polyps alone was 10.3%, hyperplastic polyps 9%, and both types 1.9%. The prevalence rate for an adenomatous polyp in patients without a hyperplastic polyp was 15%. In contrast, among patients with a hyperplastic polyp, 49% had a synchronous adenomatous polyp. Only 3.4% of patients had an adenomatous polyp proximal to the splenic flexure when no polyps were present in the left colon. Conversely, among the 29 patients in whom an isolated hyperplastic polyp was found in the left colon, there was a 32.5% prevalence of adenomatous polyps in the proximal colon (p less than 0.01). The results of this study suggest that left-sided hyperplastic colonic polyps (generally within the reach of a screening sigmoidoscopy) serve as a marker for neoplastic polyps.

The role of endoscopic retrograde cholangiopancreatography injection training sessions for the gastroenterology nurse and associate.

Pancreatitis is a recognized serious complication of endoscopic retrograde cholangiopancreatography (ERCP). The pressure with which contrast media are injected may be a risk factor for developing pancreatitis. We, therefore, designed a study to determine if there were differences in pressures generated by experienced and inexperienced gastroenterology nurses and how much training would be required to instruct individuals to inject to a specific pressure. With the use of manometrically guided practice sessions, it was determined that inexperienced operators initially inject with significantly high pressure but can learn to inject accurately to a specific pressure as rapidly as experienced operators. Injection training sessions may be beneficial in minimizing the potential risk factor of hydrostatic pressure induced endoscopic retrograde cholangiopancreatography-associated pancreatitis.

Use of endoscopic ultrasound in patients with esophageal motility disorders.

New technology has combined the endoscope with ultrasound in an effort to enhance the visualization of the gastrointestinal tract. With a modified standard endoscope that has an ultrasound transducer built into the tip, high frequency ultrasonic beams can be targeted in close proximity to existing lesions. This results in better quality resolution which enhances the evaluation of the targeted lesion. In addition, esophageal wall thickness can be evaluated and assessed as to its role in esophageal function.