Non-variceal upper gastrointestinal bleeding and Forrest's classification: diagnostic agreement between endoscopists from the same area.

BACKGROUND AND STUDY AIMS: The lack of uniformity in defining the stigmata of hemorrhage in patients with bleeding ulcers is suggested by the wide range among published studies in prevalence and rebleeding rates for the same stigmata. Moreover there is, in published trials of endoscopic hemostasis, little standardization of definitions of stigmata of hemorrhage. The aim of this study was to assess the interobserver agreement among endoscopists from the same area (Piedmont and Valley of Aosta). PATIENTS AND METHODS: A workshop for 47 expert endoscopists was organized in order to evaluate their agreement in the diagnosis of stigmata of recent hemorrhage, according to Forrest's classification. During the meeting 25 videotapes from endoscopic examinations of patients with recent non-variceal bleeding were shown to the 47 endoscopists, who were asked to classify every lesion. RESULTS: The overall and beyond chance interobserver agreement was calculated by means of the kappa statistic. The overall agreement among endoscopists was highly significant (p < 0.001, kappa=0.60), while the beyond chance agreement varied from excellent to good for lesions with active bleeding (kappa=0.76 and kappa=0.61 for FIA and FIB lesions respectively), whereas for lesions with stigmata of recent hemorrhage kappa varied from 0.44 to 0.49. CONCLUSIONS: These data suggest the need for better knowledge of endoscopic criteria, in order to evaluate the results of endoscopic therapy and to assess new treatments.

[Percutaneous endoscopic gastrostomy]. / Gastrostomia endoscopica percutanea.

Surgical gastrostomies were first performed in the middle of the 19th century and modified during the following years, but the most important technical improvement was percutaneous endoscopic placement (PEG), in 1980 by Ponsky and Gauderer. This technique doesn't require anesthesia and it in possible also in patients with contraindications to surgical gastrostomy. The simple procedure involves a shorter hospitalization, lower risks and reduced costs. Many authors already reported the good results of this new technique, that can be performed on a day-hospital regimen as well. The main indications are head and neck cancers, neurologic diseases involving food intake capacity, cancer cachexia, obstruction of the GI tract when there is enough space for an endoscopic procedure. Every disease that can compromise food intake for a period longer than 60 days can find an indication in placing a percutaneous gastrostomy. The advantage for the patient is a much better psychological tolerance compared with a naso-gastric tube. Also the incidence of mechanical complications of a PEG is much lower. In our experience from October '90 to July '92 we followed 34 patients with PEG, 22 males and 12 females, with mean age of 69 years (range 41-88). We used 9-French tube placed using the pull-method technique. All patients received antibiotic therapy for 5 days. About 12 hours after PEG placement all patients began using the gastrostomy, initially with the administration of electrolyte solutions and later with enteral polymeric formulas. The constant increase led all patients to a 1500 non protein calories daily intake in 3-4 days.(ABSTRACT TRUNCATED AT 250 WORDS)

[Endoscopic therapy of giant choledochal calculosis]. / Terapia endoscopica della calcolosi coledocica gigante.

The paper reports the results of conventional endoscopic treatment in 100 consecutive cases of giant lithiasis of the common bile duct. A giant calculus is one whose dimensions exceed 2 cm. Endoscopic therapy proved successful in 73% of cases, with an 8% incidence of complications. The success of endoscopic treatment is related to the anatomical conditions of the biliary tract and the diameter of calculi. Mechanical lithotripsy has proved efficacious in all cases where it was used, whereas poor results were obtained using MTBE infusion through a naso-biliary tube. ESWL provided encouraging results. Cases which were not resolved using endoscopic methods were treated using intervention radiology or surgery, or both.