Pneumatic balloon dilation for esophageal achalasia.

Pneumatic balloon dilation remains the medical treatment of choice for patients with achalasia. It is superior to other medical therapies including intrasphincteric botulinum toxin injection. The overall efficacy rate for long-term excellent or good result is 80 to 85%. It is extremely important that the endoscopist be quite experienced in the technique of pneumatic dilation and develop a standard protocol to minimize the complications. The technique of graded balloon dilation starting with 3.0-cm Rigiflex balloon as the initial dilator and progressing to 3.5-cm and 4.0-cm balloon in absence of response to previous balloon size offers the safest approach. Patients not responding to three serial dilations should be offered surgery, although some patients may prefer repeat dilations to surgery. The overall complication rate for Rigiflex dilation is about 3% and for Witzel dilation is about 6%. Some patients will develop GER when measured by 24-hour esophageal pH monitoring, but most patients remain asymptomatic.

Acute effect of nicotine patch on gastric emptying of liquid and solid contents in healthy subjects.

The effect of nicotine on gastric emptying remains controversial. Gastric emptying is delayed in chronic smokers after smoking high-dose nicotine cigarettes, but it is unchanged after chewing nicotine gums. No information is available on the effect of transdermal nicotine patches on the gastric emptying of solid and liquid contents in healthy nonsmokers. Our objective was to prospectively evaluate the effect of the nicotine patch on gastric emptying of liquid and solid contents in healthy nonsmokers. Ten healthy nonsmoking volunteers underwent a baseline dual-isotope gastric scintigraphy with [111In]-diethylenetriaminepantaacetic acid (DTPA) and [99mTc]sulfur colloid isotopes to evaluate prospectively the gastric emptying of liquid and solid contents, respectively. The gastric scintigraphy was repeated after placing a transdermal nicotine patch (Habitrol) for 12 hr designed to deliver 14 mg of nicotine per day. Plasma nicotine level was measured prior to baseline gastric scintigraphy and after 12 hr placing the nicotine patch. Plasma nicotine was absent in all subjects at baseline and but was significantly elevated after 12 hr of nicotine patch (P < 0.009). The mean half-emptying times (T1/2) for the gastric emptying of liquids before and after nicotine patch placement were 31.2+/-23.3 and 25.6+/-8.4 min, respectively (P = 0.498). The mean T1/2s for the gastric emptying of solids before and after nicotine patch placement were 70.1+/-34.0 and 59.7+/-31.4 min, respectively (P = 0.202). There was no correlation between the plasma nicotine level and gastric emptying of liquid and solid contents (correlation coefficient = -0.23 and -0.01, respectively). In conclusion, acute transdermal delivery of nicotine does not affect the gastric emptying of solid and liquid contents in healthy nonsmoking subjects.

Utility of preoperative fiberoptic flexible sigmoidoscopy in the evaluation of patients with suspected gynecologic malignancy.

BACKGROUND: Fiberoptic flexible sigmoidoscopy (FFS) is routinely requested preoperatively as part of evaluation of pelvic masses to exclude colonic involvement by the tumor or concurrent colonic neoplasm. The aim of our study was to evaluate the utility of preoperative FFS in patients with suspected gynecologic malignancy. METHODS: FFS, performed using a 60 cm sigmoidoscope, evaluated (1) presence of bowel involvement by the tumor, (2) extrinsic compression by the tumor, and (3) presence of colonic neoplasms. FFS findings were correlated with surgical findings. RESULTS: A total of 107 women underwent preoperative FFS and subsequent surgery. Eleven patients (11%) had lower gastrointestinal symptoms. At surgery, 63% of pelvic tumors were malignant and 37% were benign. The most common abnormality at FFS was colonic polyps in 23 patients (21%). Colonic adenomas were found in 11 patients (10%). Extrinsic compression by the tumor without mucosal abnormalities was seen in 15 patients (14%). The most common intraoperative finding was tumor adhering to the bowel in 18 patients requiring dissection, but only 1 patient required bowel resection. Eight of these 18 patients had preoperative lower gastrointestinal symptoms. All 15 patients with extrinsic compression at FFS had tumor adhering to the bowel. CONCLUSIONS: Pelvic masses cause extrinsic compression at FFS in 14% of patients. This is suggestive of tumor adherent to the bowel at surgery. However, bowel resection is rarely required because of tumor involvement. Most patients with bowel adherence by tumor have lower gastrointestinal symptoms. Colonic adenomas are found in one tenth of patients, mostly in patients older than 50 years of age. Preoperative FFS does not change the surgical management of pelvic tumors. Screening FFS is indicated in all patients with pelvic tumors over age 50, as in persons with average risk, but is otherwise unnecessary in evaluation of pelvic masses.

India ink tattooing in the esophagus.

BACKGROUND: Precise endoscopic measurement of esophageal landmarks is difficult and inaccurate because of the ability of the esophagus to lengthen and foreshorten. METHODS: Nineteen patients enrolled to date in a study of Barrett's esophagus had an India ink tattoo placed at the most proximal level of the squamocolumnar junction and were examined endoscopically at 3, 9, 15, 24, and 36 months. RESULTS: Eighteen of nineteen patients (94.7%) were judged to have a good to excellent tattoo persistence at 3 months. One of the 19 patients (5.3%) had poor tattoo persistence and was retattooed at the 3-month interval. Eventually, 15 of the 15 patients (100%) who remained in the study had a good or excellent tattoo persistence at 36 months. There were no complications related to India ink tattooing including chest pain, bleeding, or perforation. At follow-up endoscopy, no ulcers, inflammation, break in the mucosa, or pain were noted. CONCLUSION: India ink tattooing in the esophagus is safe and persistent and may be used as an effective method for longitudinal follow-up of lesions in the esophagus.

Transforming growth factor alpha distribution in rectal crypts as a biomarker of decreased colon cancer risk in patients consuming cellulose.

Data from rat experimental carcinogenesis studies indicate that supplemental dietary cellulose reduces the incidence of colon cancer. Epidemiology studies also indicate that high dietary fiber reduces the risk of colorectal cancer in humans. Patients diagnosed with sporadic adenomas were entered into a randomized clinical trial to determine if supplemental dietary cellulose would reduce the patients' risk for colon cancer. Immunohistochemical staining for transforming growth factor alpha (TGF-alpha) was done on biopsies of rectal mucosa taken from patients at the time of initial polypectomy and 1 year later. Results were evaluated for utility as a surrogate end point biomarker for reduction in colon cancer risk. There was a significant decrease in the fraction of the rectal crypt cells that stained for TGF-alpha in six of seven of the patients given the cellulose supplements but in only one of six of the patients not given cellulose. Thus, whether evaluated as a group or in individual patients, there was a significant decrease in TGF-alpha in rectal crypts due to cellulose intervention, which correlated with the expected ability of supplemental dietary cellulose to decrease the risk for colon cancer. Long-term testing of the ability of dietary cellulose to reduce adenoma recurrence is under way to validate the use of TGF-alpha as a surrogate end point biomarker.

Effects of transdermal nicotine on lower esophageal sphincter and esophageal motility.

Cigarette smoking has been shown to decrease lower esophageal sphincter pressure (LESP) by 19-42%. This decrease in LESP may be due to nicotine in the cigarette smoke or substances other than nicotine. The aim of this study was to evaluate the effects of a nicotine patch on esophageal motility since nicotine patches are devoid of all toxins present in the cigarette smoke except the nicotine. Ten healthy nonsmoking volunteers underwent baseline esophageal manometry. Esophageal manometry was repeated after placing a nicotine transdermal patch (Nicotrol) designed to deliver 15 mg of nicotine per day. The parameters that were compared included LESP by rapid pull-through (LESP-RPT) and station pull-through (LESP-SPT), LES relaxation, and velocity, amplitude, and duration of esophageal contractions. Plasma nicotine and cotinine levels were measured prior to baseline manometry and after 12 hr of placing the nicotine patch, the LESP-RPT decreased by 31% from 17.4 +/- 6.1 to 12.1 +/- 3.3 (P = 0.013) and the LESP-SPT by 27% from 13.4 +/- 5.4 to 9.8 +/- 4.8 (P = 0.029) after the nicotine patch. LES relaxation was present in 100% before and after nicotine patch. There were no significant differences in velocity, duration, and amplitude of esophageal contractions after the nicotine patch. Plasma nicotine and cotinine was absent in all subjects at baseline but was significantly elevated after 12 hr of nicotine patch. Transdermal delivery of nicotine results in a significant reduction in LESP in healthy subjects without effecting LES relaxation or esophageal body motility.

Gastrointestinal endoscopy in patients taking antiplatelet agents and anticoagulants: survey of ASGE members. American Society for Gastrointestinal Endoscopy.

BACKGROUND: Gastrointestinal endoscopy is often required in patients taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or anticoagulants. Because proper guidelines are lacking, we believe that most endoscopists use their own criteria and judgment for stopping and restarting these agents during the periendoscopic period, and the practice varies widely. The aim of our study was to identify these practices among ASGE members. METHODS: Questionnaires, each containing 22 questions with 157 responses, were sent to 3300 ASGE members, including all Gastroenterology Fellowship Program Directors. One thousand two hundred sixty-nine questionnaires were received and analyzed. RESULTS: Physicians stopped aspirin and NSAIDs more frequently before colonoscopy (81%) and ERCP (79%) than before upper endoscopy (51%) (p < 0.001). Ninety percent of physicians stopped aspirin and NSAIDs for 10 or fewer days. Only 20% of physicians performed sphincterotomy when aspirin and NSAIDs were not stopped compared with 88% and 85% (p < 0.001 for both) of physicians performing cold biopsies at esophagogastroduodenoscopy and colonoscopy, respectively, and 77% and 69% performing hot biopsies for the same procedures (p < 0.001 for all compared with sphincterotomy). Depending on the indication for anticoagulation, 51% to 60% of physicians stopped warfarin before upper endoscopy; 71% to 82% before colonoscopy; and 26% to 51% of physicians used a "heparin window." All physicians restarted warfarin immediately after diagnostic endoscopy, whereas 80% restarted it 7 or fewer days after therapeutic endoscopy. CONCLUSIONS: We conclude that a wide variation exists regarding the management of aspirin, NSAIDs, and anticoagulants in the periendoscopic period. There is a definite need for a consensus statement or guidelines for managing patients taking these agents.

Prevalence of proximal colonic polyps in average-risk asymptomatic patients with negative fecal occult blood tests and flexible sigmoidoscopy.

BACKGROUND: Proximal colonic adenomas were found in 13% to 37% of patients without distal adenomas who underwent colonoscopy. Fiberoptic flexible sigmoidoscopy (FFS) was not performed prior to colonoscopy in all studies except one. The proximal colon at colonoscopy was defined as that portion of the colon proximal to either the descending-sigmoid junction or 60 cm from the anus while withdrawing the colonoscope. These estimates may not reflect exact colonic location when a 60 cm length sigmoidoscope is fully inserted. Therefore, the aim of our study was to determine the prevalence of proximal colonic neoplasms in asymptomatic patients with average risk for colon cancer, aged 50 years and over, with negative fecal occult blood tests and without adenomas at FFS. METHODS: Colonoscopy was performed in 80 patients without and 95 patients with adenomas at FFS. Polypectomy was done using hot biopsy forceps or snare cautery. RESULTS: Twenty-four proximal colonic adenomas (19 < 1 cm and 5 > or = 1 cm) were found in 18 of 80 patients (23%) with normal FFS compared with 39 proximal colonic adenomas (32 < 1 cm and 7 > or = 1 cm), in 28 of 95 patients (29%) with adenomas at FFS (p = 0.31). In patients with normal FFS, there were 20 tubular, 2 tubulovillous, and 2 villous (1 with severe dysplasia) adenomas. In patients with adenomas at FFS, there were 31 tubular, 5 tubulovillous, and 3 villous (1 with severe dysplasia) adenomas. CONCLUSIONS: Proximal colonic adenomas are found in up to one fourth of asymptomatic average-risk patients with negative fecal occult blood test and both with and without adenomas at FFS. The adenomas in both groups have similar size, histology, and location. Severe dysplasia is rarely present.

Effect of cigarette smoking on gastroesophageal reflux measured by 24-h ambulatory esophageal pH monitoring.

OBJECTIVE: We reassessed the effect of cigarette smoking on gastroesophageal reflux because two previous ambulatory 24-h pH monitoring studies showed equivocal results and did not relate heartburn to changes in pH reflux events. METHODS: Our protocol design considered nicotine's pharmacokinetic half-life; 14 smokers with heartburn and esophagitis abstained from smoking for 48 h before and during an ambulatory 24-h esophageal pH monitoring study (24-h pH). After resuming their smoking habits for 48 h or more, they underwent a second 24-h pH study and smoked 20 regular, filtered Marlboro cigarettes. Acid reflux was defined as a drop in intraesophageal pH to a value < 4 at 5 cm above the lower esophageal sphincter and was measured as percent exposure and reflux events (total N, those > or = 5 min, and longest event). Heartburn episodes were noted by the patients and were correlated later to acid reflux events. RESULTS: Cigarette smoking significantly increased the percentage time that the pH was < 4 during a 24-h period from 7.35 to 11.1% (medians; p < 0.007). This increased exposure occurred predominantly during the day while in the upright posture and resulted from significant increases in both reflux events and those parameters that measure acid clearance (T events > or = 5 min and longest event). While smoking, the patients noted a 114% increase in daytime heartburn episodes that immediately followed a pH reflux event (3.5 to 7.5 episodes, medians; p < 0.009). CONCLUSIONS: Smoking 20 cigarettes has a greater effect on acid reflux and heartburn than purported.

Prospective evaluation of gastrointestinal tract in patients with iron-deficiency anemia.

Gastrointestinal bleeding is believed to cause iron-deficiency anemia (IDA). The information concerning ideal evaluation of the gastrointestinal tract and exact findings in patients with IDA is scant. The aim of this study was to prospectively evaluate patients with IDA for gastrointestinal lesions potentially causing IDA at a US Army Teaching Medical Center with Gastroenterology Fellowship. Seventy patients with IDA had esophagogastroduodenoscopy (EGD) and colonoscopy, and if this evaluation was unremarkable, then small bowel biopsy was obtained at EGD to evaluate for celiac disease. Enteroclysis was done if endoscopic evaluation was negative. At endoscopy, at least one lesion potentially accounted for the IDA in 50 (71%) patients. At colonoscopy, 21 (30%) patients had 22 lesions (four colon cancer, seven adenoma > 1 cm, six vascular malformation, four severely bleeding hemorrhoids, one ileal Crohn's); at EGD, 39 (56%) patients had 43 lesions (11 gastric erosion, 10 esophagitis, four vascular malformation, four celiac disease, three gastric cancer, three gastric ulcer, three duodenal ulcer, two gastric polyp > 1 cm, one duodenal lymphoma, one esophageal cancer, and one duodenal Crohn's). Twelve (17%) patients had both upper and lower gastrointestinal tract lesions. Twenty-four of 32 (75%) patients with positive fecal occult blood test had potentially bleeding lesions compared to 24 of 38 (63%) patients with negative fecal occult blood test (P > 0.05). Six of nine patients with malignancy had positive fecal occult blood test. Twenty patients with normal endoscopy and small bowel biopsy had normal enteroclysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Choledochal cyst mimicking a pancreatic pseudocyst.

Choledochal cyst mimicking a pancreatic pseudocyst radiographically has not yet been reported. We report such a patient with a choledochal cyst whose initial presentation was acute pancreatitis. Ultrasound and computed tomography scan showed images that resembled a pancreatic pseudocyst.

D-lactic acidosis in a patient with jejunoileal bypass.

D-Lactic acidosis is an unique complication of jejunoileal bypass occurring because of alteration of colonic bacterial flora with selective proliferation of D-lactate-producing bacteria. The D-lactate accumulation in the serum is associated with encephalopathy, which responds to oral antibiotic drugs in most patients. Because gastroenterologists may encounter such patients for some time to come, we report a new case and review the literature.

Cytomegalovirus in upper gastrointestinal ulcers.

Cytomegalovirus (CMV), an important cause of severe infections in immunocompromised patients, can cause ulcerations anywhere in the gastrointestinal tract, most commonly stomach and colon. Only a few cases of CMV inclusions in gastrointestinal ulcers have been reported in normal hosts. We undertook a prospective study of the incidence of CMV in gastroduodenal ulcerations in immunocompetent patients. Thirty-eight patients who were referred for evaluation of dyspepsia, hematemesis, melena, guaiac-positive stools, or iron deficiency anemia and who had gastric or duodenal ulcerations without stigmata of recent hemorrhage or visible vessel were enrolled in the study. Six biopsies obtained from the ulcer base and margin were submitted for histologic examination, shell-vial viral cultures, and monoclonal antibody testing. Thirty-two patients had gastric ulcer and six had duodenal bulbar ulcer ranging in size from 8 to 20 mm in diameter. Forty-four percent of patients had been taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) within 10 days of ulcer discovery. Evaluation of all biopsies in 38 patients failed to document any evidence of CMV by light microscopy, viral cultures, or monoclonal antibody testing. CMV infection is uncommon in the gastrointestinal tract of immunocompetent patients with gastroduodenal ulcers. Even within areas of previous mucosal injury induced by nonsteroidal drugs, no evidence of CMV "superinfection" was found. We conclude that CMV infection is not a significant factor in routine peptic or NSAID-induced ulcer disease, and the discovery of CMV inclusions in gastroduodenal ulcerations should lead to a search for an immunocompromised state.

Effects of large-volume paracentesis on pulmonary function in patients with tense cirrhotic ascites.

Large-volume paracentesis is an accepted therapeutic modality for the treatment of tense ascites in patients with cirrhosis. Whereas the effects of large-volume paracentesis on the cardiovascular system have been studied in great detail, the effects of tense ascites and large-volume paracentesis on the respiratory system have undergone only limited evaluation. Most patients report symptomatic improvement in breathing after large-volume paracentesis. The aim of our study was to prospectively evaluate the effects of large-volume paracentesis on the pulmonary function of patients with tense ascites. Nine patients with alcoholic cirrhosis and tense ascites underwent large-volume paracentesis (mean, 3,500 ml of ascites removed) followed by intravenous albumin infusion (10 gm/L ascites removed). Pulmonary function tests were performed just before and 2 hr after large-volume paracentesis. The functional residual capacity increased from 2.46 +/- 0.92 to 2.99 +/- 0.97 L (p = 0.01) and total lung capacity from 5.08 +/- 1.18 to 5.72 +/- 1.32 L (p = 0.03). The forced vital capacity, expiratory reserve volume and residual volume also increased but were not statistically significant (p = 0.07 for all). We noted no significant improvement in forced expiratory volume in 1 sec, forced expiratory effort 25% to 75%, vital capacity or diffusion capacity. There was marked symptomatic improvement in all patients. We conclude that large-volume paracentesis improves measured lung volumes within hours in patients with tense ascites.

Comparison of Foley catheter as a replacement gastrostomy tube with commercial replacement gastrostomy tube: a prospective randomized trial.

Percutaneous endoscopic gastrostomy (PEG) provides a non-surgical alternative to long-term enteral feeding. The gastrostomy tube, however, may deteriorate, malfunction, or be accidentally expelled, requiring replacement. A commercial gastrostomy tube is commonly used for replacement. However, a commercial replacement gastrostomy tube is many times more expensive than a Foley catheter, and the two have never been compared. We compared the efficacy and safety of an all-silicone Foley catheter used as a replacement feeding gastrostomy tube with the effectiveness of a commercial replacement gastrostomy tube in 46 patients undergoing long-term enteral feedings per gastrostomy. Twenty-four patients were randomized to the Foley group and 22 patients to the commercial replacement gastrostomy tube group. The Foley catheter functioned well without need for replacement in 16 (66%) patients for 27.4 +/- 14.8 (mean +/- SD) weeks; the commercial replacement gastrostomy tube functioned in 13 (59%) patients for 24.5 +/- 13.6 weeks (p > 0.05, NS). The Foley catheter needed to be replaced because of malfunction in 8 (34%) patients and the commercial replacement gastrostomy tube in 9 (41%) patients after 21.6 +/- 11.5 weeks and 19.3 +/- 9.3 weeks, respectively (p > 0.05, NS). Neither the Foley catheter nor the commercial replacement gastrostomy tube migrated; this was the most striking finding, in contrast to case reports in the literature. Our data suggest that the Foley catheter can be safely used as a replacement gastrostomy tube; it is considerably cheaper than the commercial replacement gastrostomy tube, and its efficacy and complication rates are similar to those of the commercial replacement gastrostomy tube.