Validation of a graded response questionnaire for the diagnosis of gastroesophageal reflux disease in an Asian primary care population.

BACKGROUND: Diagnosis of gastroesophageal reflux disease (GERD) based on subjective evaluation of symptoms alone is challenging. GOALS: To test the validity and reliability of a graded response questionnaire to identify patients with GERD. STUDY: Patients presenting with upper abdominal symptoms for more than a month, and without alarm features were consecutively recruited. They completed a 12-item questionnaire encompassing 6 symptoms presented either in Chinese or English language. Scores were analyzed for validity in diagnosis of GERD, using gastroenterologist's diagnosis as reference standard. Receiver operating characteristic (ROC) analysis, predictive values, likelihood ratios, and diagnostic odds ratio were used to evaluate diagnostic accuracy. RESULTS: Of 209 patients studied, 163 (78%) answered the English whereas 45 (21.5%) answered the Chinese version. At a cut-off of > or =28.5 in total symptom scores, the Chinese version had a sensitivity of 87.5% and specificity of 75.7% with an area under the ROC curve (AUCROC) of 0.824 for diagnosis of GERD. Corresponding sensitivity and specificity for the English version were 76.9% and 50.8%, respectively, with an AUCROC of 0.760. Positive predictive value, negative predictive value, positive likelihood ratio (+LR), negative likelihood ratio (-LR), and diagnostic odds ratio were 0.438, 0.966, 3.597, 0.165, and 21.778 and 0.330, 0.875, 1.564, 0.454, and 3.443 for the Chinese and English versions, respectively. CONCLUSIONS: The questionnaires demonstrated good construct reliability, which were highly sensitive and reasonably specific for the detection of GERD. They are useful tools to help primary care physicians in identifying GERD in patients presenting with uninvestigated upper abdominal symptoms.

An unusual case of giant ileal diverticulum-A case report.

Small bowel diverticulosis is rare with an incidence of 1-2% in the general population. It is an uncommon cause of gastrointestinal bleeding that ranges from obscure to overt bleeding. Large ileal diverticula are extremely rare and bleeding complications can result in high overall mortality. A young gentleman presented with persistent per-rectal bleeding and drop in hemoglobin level. He was recently diagnosed with acute myeloid leukemia and was undergoing chemotherapy. A computed tomography scan of the abdomen and pelvis revealed a giant ileal diverticulum. In view of on-going bleeding, he underwent double balloon enteroscopy which revealed active bleeding from an ulcer within the giant ileal diverticulum and successful hemostasis was performed with hemostatic clips. Small bowel diverticulosis though uncommon has to be considered during workup for gastrointestinal bleeding. Endoscopic treatment is a modern approach towards small bowel diverticular bleeding that is effective and less invasive.

Esophageal Metastatic Adenocarcinoma Diagnosed with Endoscopic Ultrasound.

Metastasis to the esophagus from a distant primary cancer is a rare manifestation in a patient with a history of oncological disease presenting with obstructive upper gastrointestinal symptoms. Computed tomography of the thorax or esophagogastroduodenoscopy can be non-diagnostic as the disease tends to be submucosal. In such a situation, endoscopic ultrasound (EUS) with fine needle aspiration (FNA) can be directed to characterize and sample the submucosal esophageal lesion. We present a case series of metastatic esophageal strictures diagnosed with EUS and FNA.

Complications of endoscopic retrograde cholangiography in the post-MRCP era: a tertiary center experience.

AIM: To evaluate our experience in endoscopic retrograde cholangio-pancreatography (ERCP) in terms of fulfilling the ASGE guidelines in indications, positive findings, and complications in the post-magnetic resonance cholangiopancreatography (MRCP) era. METHODS: Between November 2001 and February 2003, consecutive ERCP cases were prospectively evaluated with regard to the indications, findings, cannulation techniques, devices used during the procedure, sedation given, duration of procedure, and complications. These data were entered in a database for subsequent processing and analysis. RESULTS: Of 336 cases, 21.4% were diagnostic and 78.6% therapeutic ERCP. The indications for ERCP fulfilled the ASGE guidelines in 323 cases (96.1%). Suspected bile duct stone was the most frequent indication (26.8%), and this was followed by cholangitis (24.4%), dilated common bile duct (14.9%), and cholestatic jaundice (13.4%). Cannulation success rate was 94%. Biliary sphincterotomy was performed in 175 (52.1%) patients. Repeated ERCP was performed on 31.5% of the patients. Overall, the complication rate was 9.8% with 0.3% being procedure-related mortality. The complications were pancreatitis (5.4%), bleeding (0.8%), cholangitis (2.4%) and others (1.5%). No significant difference was observed between the complication rate and the type of ERCP performed. CONCLUSION: Our study showed that post-ERCP complication rate was comparable with the other large prospective studies and there was no difference in the complication between the diagnostic and therapeutic ERCP.

Suspected oesophageal cancer in a 33 year old lady.

A previously healthy 33 year old lady presented with acute dysphagia with endoscopic and CT features of oesophageal carcinoma. Endoscopic ultrasound (EUS) revealed a large subcarinal lymph node compressing at the mid-oesophagus. Fine-needle aspiration (FNA) showed a single well-formed epithelioid granuloma with no evidence of malignancy. Molecular analysis showed the aspirate to be positive for Mycobacterium tuberculosis. She continues to improve with standard anti-TB medication without surgery.This is a rare case of acute dysphagia secondary to primary tuberculous mediastinal lymphadenopathy. EUS and FNA have completely altered the clinical management of this lady.