Beverly J. Ott

A 21-year experience with major hemorrhage after percutaneous liver biopsy

Nine thousand two hundred twelve liver biopsies were performed according to a defined protocol, and data were prospectively recorded to identify risk factors for major bleeding. There were 10 fatal and 22 nonfatal hemorrhages (0.11% and 0.24%, respectively). By comparison with a control group that did not hemorrhage, malignancy, age, sex, and the number of passes were the only predictable risk factors. The risk of fatal hemorrhage in patients with malignancy is estimated to be 0.4%; for nonfatal hemorrhage, 0.57%. In patients undergoing liver biopsy for nonmalignant disease, the risks are 0.04% and 0.16%, respectively.

Impact of endoscopist withdrawal speed on polyp yield: Implications for optimal colonoscopy withdrawal time

In 2002, a U.S. Multi‐Society Task Force on Colorectal Cancer recommended that the withdrawal phase for colonoscopy should average at least 6–10 min. This was based on 10 consecutive colonoscopies by two endoscopists with different adenoma miss rates.

Performance standards for therapeutic abdominal paracentesis

Large‐volume paracentesis, the preferred treatment for patients with symptomatic tense ascites due to cirrhosis, has traditionally been performed by physicians as an inpatient procedure. Our objectives were to determine (1) whether large‐volume paracentesis could be performed safely and effectively by gastrointestinal endoscopy assistants and as an outpatient procedure, (2) whether the risk of bleeding was associated with either thrombocytopenia or prolongation of the prothrombin time, and (3) the resources used for large‐volume paracentesis. Gastrointestinal endoscopy assistants performed 1,100 large‐volume paracenteses in 628 patients, 513 of whom had cirrhosis of the liver. The preprocedure mean international normalized ratio for prothrombin time was 1.7 ± 0.46 (range, 0.9‐8.7; interquartile range, 1.4‐2.2), and the mean platelet count was 50.4 × 103/μL, (range, 19 × 103/μL − 341 × 103/μL; interquartile range, 42‐56 × 103/μL). Performance of 3 to 7 supervised paracenteses was required before competence was achieved. There were no significant procedure‐related complications, even in patients with marked thrombocytopenia or prolongation in the prothrombin time. The mean duration of large‐volume paracentesis was 97 ± 24 minutes, and the mean volume of ascitic fluid removed was 8.7 ± 2.8 L. In conclusion, large‐volume paracentesis can be performed safely as an outpatient procedure by trained gastrointestinal endoscopy assistants. Ten supervised paracenteses would be optimal for training the operators carrying out the procedure. The practice guideline of the American Association for the Study of Liver Diseases which states that routine correction of prolonged prothrombin time or thrombocytopenia is not required is appropriate when experienced personnel carry out paracentesis. (HEPATOLOGY 2004;40:484–488.)

Complications of Endoscopic Retrograde Cholangiopancreatography in Primary Sclerosing Cholangitis

OBJECTIVES:Endoscopic retrograde cholangiopancreatography (ERCP) is commonly performed in patients with primary sclerosing cholangitis (PSC). The risk of complications associated with this procedure is not well established in these patients. The aim of this retrospective study was to compare the risk of ERCP complications in PSC vs. non-PSC patients.METHODS:We identified all Mayo Clinic patients who underwent ERCP in 2005. Procedural and clinical data were collected. Complications were defined as hospitalizations for pancreatitis, cholangitis, perforation, and bleeding.RESULTS:A total of 168 patients with PSC and 981 patients without PSC had at least one ERCP examination in the calendar year 2005. PSC patients were younger (48 years±15 vs. 60 years±19, P<0.000) and had a higher prevalence of portal hypertension (31.5% vs. 4%, P<0.0001). PSC patients had more biopsies (39% vs. 15%, P<0.0001), brushings (37% vs. 8%, P<0.001), balloon dilatations (48% vs. 15%, P<0.0001), duct cytology (20% vs. 3%, P<0.0001) and intraductal ultrasounds (11% vs. 5%, P=0.007) than non-PSC patients. The duration of the procedure was longer in the PSC group (51 min±29 vs. 40 min±28, P<0.0001). The overall rate of complications in patients with PSC when compared to non-PSC patients was not significantly different (18/168 (11%) vs. 76/981(8%), P=0.2). The incidence of cholangitis was higher in the PSC group (4% vs. 0.2%, P<0.0002) despite routine use of antibiotics before the procedure in PSC patients. The duration of the procedure was longer in PSC patients who developed cholangitis (86 min±28 vs. 51 min±29, P=0.02). The risks of complications such as pancreatitis, perforation, and bleeding were not significantly different between the two groups despite their demographic and procedural variations. The duration of hospitalization due to complications was also not significantly different between the two groups.CONCLUSIONS:Complications requiring hospitalizations occur in over 10% of PSC patients undergoing ERCP. Cholangitis occurs more often in PSC patients and correlates with the length of the procedure. Further studies to confirm the role of aggressive prophylactic antibiotics in patients with PSC who undergo prolonged procedures are warranted.

Balloon Dilatation of Upper Digestive Tract Strictures

The results of balloon dilatation of upper digestive tract stricture in 111 patients were evaluated. Eighty-eight patients had esophageal strictures and 23 had gastric or pyloric strictures. Thirty-six patients had strictures associated with previous operations. Twenty-two percent of the patients with esophageal strictures had malignancies. Overall, 92% were successfully dilated, with a complication rate of 3%. Follow-up information was available in 95% of patients. Eighty-seven percent of living patients experienced symptomatic improvement, which lasted for a median period of 12 mo. Forty percent required a further procedure during the period of follow-up. We found no difference between esophageal strictures and gastric or pyloric strictures in success rate, complications, or need for further dilatation, although patients with esophageal strictures were more apt to have symptomatic improvement. Postoperative strictures responded as well as nonoperative strictures. Previously dilated strictures in patients with esophageal reflux were managed as successfully as strictures never before dilated. We found balloon dilatation of upper digestive tract stricture to be a safe, effective technique.

Effect of varying doses of chenodeoxycholic acid on bile lipid and biliary bile acid composition in gallstone patients: A dose-response study

In a dose-response study, a formulation of chenodeoxycholic acid (chenic acid) with complete bioavailability was fed at doses of 0,250, 500, 750 mg for randomized 6-week periods to 13 patients with radiolucent gallstones. The proportion of chenic acid in biliary bile acids increased in direct relation to dose. Lithocholic acid also increased, but ursodeoxycholic acid showed no significant change. Bile saturation decreased with increasing dose, but response was variable and achieved significance only at 750 mg/day. Cholesterol saturation was negatively correlated with the proportion of chenic acid in biliary bile acids: When biliary bile acids contained greater than 70% chenic acid (and ursodeoxycholic acid), bile became unsaturated, on the average. The data suggest that a dose of at least 10–15 mg/kg may be necessary to obtain desaturation in many gallstone patients.

Differing effects of ursodeoxycholic or chenodeoxycholic acid on biliary cholesterol saturation and bile acid metabolism in man - A dose-response study

A dose-response study comparing ursodeoxycholic and chenodeoxycholic acid was carried out in six men with asymptomatic radiolucent gallstones present in well-visualizing gallbladders. The study tested the effects of a low (averaging 6 mg/kg/day) or medium dose (averaging 11 mg/kg/day) of each bile acid on the cholesterol saturation of bile as well as on bile acid metabolism, as inferred from biliary and fecal bile acid composition. Ursodeoxycholic acid, at low or medium doses, induced bile desaturation in most patients, whereas chenodeoxycholic acid did not. Despite the greater desaturation efficacy of ursodeoxycholic acid, biliary bile acids became less enriched with the administered bile acid during ursodeoxycholic acid treatment than during chenodeoxycholic acid treatment. Both bile acids were nearly completely 7-dehydroxylated to lithocholic acid by colonic bacteria, but biliary lithocholic increased only slightly (and similarly) with each bile acid. Fecal bile acid composition suggested that administered ursodeoxycholic acid suppressed endogenous bile acid synthesis much less than chenodeoxycholic acid. The results indicate that ursodeoxycholic acid and chenodeoxycholic acid have similar but not identical effects on bile acid metabolism, but that for a given dose, ursodeoxycholic acid is a more potent desaturating agent than chenodeoxycholic acid. The results suggest that cholesterol gallstone dissolution with ursodeoxycholic acid should occur with a dose of 8–10 mg/kg in most nonobese patients.

Diagnostic laparoscopy in gastroenterology - A 14-year experience

Between 1970 and 1983, we performed 1121 diagnostic laparoscopies in 1119 patients. More than 50% of the examinations were performed for malignant disease. An adequate examination was accomplished in 917 (82%) procedures. The most frequent reason for inadequate evaluation was the presence of dense intraabdominal adhesions from previous surgery. We observed 105 (9.4%) minor complications and 20 (1.8%) major complications including one death following hemorrhage from liver biopsy. Major complications included abdominal wall hematoma, perforated abdominal viscus, hemoperitoneum, bleeding from liver biopsy, and respiratory depression. We observed a trend to decreased use of laparoscopy. Ascites of unknown origin and certain specific situations in patients with chronic liver disease remain as major indications for this diagnostic technique.

Prospective assessment of the impact of feedback on colonoscopy performance

Colonoscopy is an operator‐dependent procedure. The medical literature describes disparity in colonoscopy performance with respect to polyp detection, caecal intubation rates and procedural times.

The structure and function of the outpatient endoscopy unit.

The authors present an analysis of the requirements for space, equipment, and personnel for an outpatient unit. These studies were derived from personnel and procedure time studies, evaluation of equipment and maintenance costs, and utilization of space studies and should be applicable to any outpatient endoscopy unit performing more than 1000 procedures per year.