A prospective study of factors that determine cecal intubation time at colonoscopy.

BACKGROUND: For outpatient colonoscopy, the time required to intubate the cecum is variable. The aim of this study was to determine factors associated with cecal intubation time. METHODS: A total of 693 consecutive outpatient colonoscopies performed from January to October 2002 at a tertiary care medical center were studied prospectively. Data gathered included time required to reach the cecum; patient age, gender, and body mass index; history of abdominal surgery; quality of bowel preparation; presence/absence of diverticula; and endoscopist experience. RESULTS: Complete data were available for 587 patients. Mean age was 59 years, 48% were men, and mean body mass index was 28. Median cecal intubation time was 9 minutes. Linear regression analysis was performed. Cecal intubation time is prolonged by the following factors: older patient age, female gender, lower body mass index, poor bowel preparation, and lower endoscopist annual case volume. CONCLUSIONS: This large, prospective study identified 5 factors that prolong the time required for cecal intubation at colonoscopy. These factors may be used to individualize scheduling of colonoscopy according to the time required.

Most GERD symptoms are not due to acid reflux in patients with very low 24-hour acid contact times.

Ambulatory esophageal 24-hr pH monitoring is used to diagnose GERD by determining the total acid contact time and/or symptom index (SI). The aim of this study was to compare the relationship between total acid contact times and SI in two groups: patients with very low vs. very high total acid contact times. We reviewed 973 consecutive 24-hr pH studies and compared patients with the lowest and highest 5% of total acid contact times. The low reflux group was significantly younger (median 50 vs. 54 years) and more predominantly female (78 vs. 47%) than the high reflux group. Median total acid contact time was 0.6 and 26.4% in the low and high reflux groups, respectively. The median SI was significantly lower in the low vs. high reflux groups for all symptoms (heartburn, 0 vs. 100%; regurgitation, 20 vs. 100%; cough, 0 vs. 55%; chest pain, 0 vs. 75%; nausea, 0 vs. 100%; and total SI, 12 vs. 86%). In patients with very low total acid contact times, only 12% of symptoms (typical or atypical) are associated with acid reflux, compared to 86% in patients with very high acid contact times. Younger females are overrepresented in the very low reflux, low SI group.

Massive gastrointestinal hemorrhage due to rupture of a donor pancreatic artery pseudoaneurysm in a pancreas transplant patient.

Enteric drainage of secretions by anastomosing the donor duodenum to the recipient's small bowel has become common in pancreatic transplantation. While it eliminates many problems, endoscopic access to the transplanted duodenum and pancreas is made difficult. After a pancreas kidney transplant, the patient presented with massive hematochezia. Upper and lower endoscopy revealed large amounts of red blood in the colon but no specific bleeding site. Mesenteric angiography was normal but pelvic angiography showed rapid extravasation of contrast from a pseudoaneurysm of the pancreatic transplant artery. This was successfully embolized with coils. To the best of our knowledge, this is the first case of massive gastrointestinal hemorrhage because of rupture of a pseudoaneurysm of the donor pancreatic artery in a pancreas transplant patient. We report this case and review our institution's experience with all forms of gastrointestinal bleeding in pancreas transplant patients.

Marked improvement in nocturnal gastroesophageal reflux in a large cohort of patients with obstructive sleep apnea treated with continuous positive airway pressure.

BACKGROUND: Nocturnal gastroesophageal reflux (nGER) is common in patients with obstructive sleep apnea (OSA). Small, short-term studies have shown that treatment with nasal continuous positive airway pressure (CPAP) decreases esophageal acid exposure. OBJECTIVE: To examine the relationship between OSA and nGER, and the effect of CPAP on nGER, in a long-term follow-up study of a large cohort of patients with OSA and nGER. METHODS: We prospectively studied 331 patients diagnosed as having OSA between October 1, 1993, and November 30, 2000. At baseline, patients graded their frequency of nGER symptoms on a scale of 1 (never) to 5 (always). All patients were prescribed CPAP for their OSA. At follow-up, the frequency of nGER symptoms was obtained by telephone interview. RESULTS: Of the 331 patients with OSA, nGER was present in 204 (62%) before treatment with CPAP. Follow-up was obtained in 181 patients (89%). Of these 181 patients, 165 (91%) were still using CPAP and 16 (9%) were not, forming the treatment and control groups, respectively. The patients compliant with CPAP had a significant improvement in nGER score, from a mean of 3.38 before CPAP treatment to 1.75 after treatment (48% improvement; P<.001), while patients not using CPAP (control subjects) showed no improvement (mean, 3.56 to 3.44; P =.55). There was a strong correlation between CPAP pressure and improvement in nGER score (correlation, r = 0.70; P<.001), with patients with higher CPAP pressures demonstrating a greater improvement in nGER score. CONCLUSIONS: Nocturnal GER is common in patients with OSA. Treatment with nasal CPAP decreases the frequency of nGER symptoms by 48%. Higher nasal CPAP pressures are associated with greater improvement in nGER.

The cost-effectiveness of treatment strategies for achalasia.

Achalasia is a disorder characterized by abnormal motility of the esophageal body and the lower esophageal sphincter, resulting in dysphagia, regurgitation, and chest pain. Treatment options for achalasia include Botulinum toxin injection, pneumatic balloon dilation, and surgical esophagomyotomy. The aim of this study was to determine the cost-effectiveness of these three strategies in the treatment of achalasia in adults. We constructed a Markov cost-effectiveness model comparing Botox injection, pneumatic balloon dilation, and laparoscopic esophagomyotomy as initial treatments of achalasia. Costs and probabilities were derived from the published literature. The utility for symptomatic achalasia was derived from a sample of patients with achalasia. Sensitivity analyses were performed. Over a five-year time horizon, pneumatic dilation was the most cost-effective treatment strategy for achalasia, with an incremental cost-effectiveness ratio of $1348 per quality-adjusted life-year compared to Botox. Although laparoscopic esophagomyotomy was more effective than the other treatment options, it was not cost-effective because of its high initial cost. In conclusion, pneumatic dilation is the most cost-effective treatment option for adults with achalasia. Further studies should examine the long-term relapse rates following treatment with Botox and more precisely determine the quality of life of symptomatic achalasia.