Charles E. Brady

Muscle anatomy of the human esophagus

We studied the esophageal musculature of 11 cadavers to assess the distribution of striated and smooth muscle. The lower 54-62% of the esophagus was found to be exclusively smooth muscle, the proximal 4.1-5.6% to be exclusively striated, and the remainder to be mixed. The area in which striated and smooth muscle portions were approximately equal, the 50/50 point, was found to be 4.7 +/- 0.6 cm from the proximal portion of the cricopharyngeus muscle. This point corresponds to the previously described physiologic low pressure zone in the proximal esophagus.

Urinary excretion of polyethylene glycol 3350 and sulfate after gut lavage with a polyethylene glycol electrolyte lavage solution

Ingestion of an electrolyte lavage solution containing polyethylene glycol 3350 and sulfate is an effective method of cleansing the colon for diagnostic studies. Polyethylene glycol and sulfate are considered poorly absorbed from the gastrointestinal tract. Because of the quantities administered, concern exists about potential toxicity of absorption of even a small percentage, particularly for polyethylene glycol. We measured the urinary excretion of both polyethylene glycol and sulfate in normal subjects and inflammatory bowel patients. Absorption of polyethylene glycol can be assessed by measuring recovery in urine, as 85%-96% of an intravenous load is excreted in urine. Similarly, appreciable sulfate absorption would exceed renal tubular reabsorption and result in increased urinary excretion. Mean percent polyethylene glycol load recovered in urine was minimal and similar for normal (0.06%) and inflammatory bowel (0.09%) subjects. Urinary sulfate excretion after lavage was also similar for both groups and was not different from baseline. These results do not suggest the likelihood of toxicity due to polyethylene glycol 3350 or sulfate absorption during gut lavage with this solution.

Healing of severe perineal and cutaneous Crohn's disease with hyperbaric oxygen

Recurrent perineal Crohns disease can be an extremely debilitating complication that may be difficult to treat. We report a patient with progressively worsening perineal and biopsy-proven cutaneous Crohns disease that had been refractory to surgery and medical treatment (sulfasalazine, steroids, 6-mercaptopurine, metronidazole, antibiotics). As the lesions were reminiscent of problem wounds occurring in other situations, hyperbaric oxygen treatment was instituted while the patient was continued on metronidazole. Response was dramatic with almost immediate relief of symptoms and regression within 2.5 mo of wounds that had previously defied therapy for 8 yr. Clinical remission has not been sustained as four subsequent courses of hyperbaric oxygen have been given over a period of 11 mo. However, the patient has been essentially asymptomatic since her initial course and the extent of her cutaneous disease has been minimal compared with that before hyperbaric oxygen. Hyperbaric oxygen treatment is costly and should not be routinely used in every patient with perineal Crohns disease. However, this case report may herald an advance in the understanding of the pathogenesis of this complication and ultimately, its therapy.

Comparison of CO2- and N2O-induced discomfort during peritoneoscopy under local anesthesia.

The most comfortable gas for peritoneoscopy has been the subject of debate. We subjected 46 patients to double-blind comparison of carbon dioxide and nitrous oxide during initial pneumoperitoneum. The discomfort from local anesthesia was similar in both patient groups. The patients and the physicians assessment of discomfort during gas insufflation showed that carbon dioxide was more uncomfortable as perceived by the patient (p = 0.02), the physician (p = 0.0006), and objectively assessed by degree of abdominal splinting (p = 0.006). The presence of intraabdominal adhesions had no relationship to discomfort. We conclude that nitrous oxide is more comfortable for institution of pneumoperitoneum during peritoneoscopy under local anesthesia.

Acid secretion and serum gastrin levels in individuals with Campylobacter pylori

Campylobacter pylori may cause gastritis and has been proposed as an etiologic factor in the development of peptic ulcer. However, it may be an acid-sensitive microbe and before it can be implicated in the pathogenesis of peptic ulcer, it should be consistently found in ulcer patients with normal acid secretion. Thirty-six patients with C. pylori by Warthin-Starry stain underwent gastric analysis; 25 were normochlorhydric and 11 hypochlorhydric. Ulcers were present in 19 normochlorhydric patients (10, gastric; 9, duodenal) and 2 hypochlorhydric patients (gastric). Median basal acid output was higher for those with duodenal ulcer (38 mmol/h) than gastric ulcer (28 mmol/h) or miscellaneous endoscopic features (33 mmol/h). The hypergastrinemia seen in 12 patients with negative secretin provocation tests was believed to be due to various nongastrinoma conditions. Campylobacter pylori was found in 6 normogastrinemic patients with elevated acid output and in 1 gastrinoma patient with marked acid hypersecretion. Histologic chronic gastritis was present in all subjects and 29 had active chronic gastritis. Twenty-three patients were taking H2-receptor antagonists at the time of diagnosis which did not seem to interfere with culture results. Using standard acid secretory tests, we conclude that C. pylori can survive in a wide range of acid conditions.

Bowel cleansing with polyethylene glycol electrolyte lavage solution.

We reviewed our experience with an oral gut lavage solution (GoLYTELY), used as a rapid bowel cleansing preparation, and the prospective clinical trials reported in the literature to compare the overall experience with this type of preparation for colonoscopy and colon surgery. Five studies (546 patients) compared GoLYTELY to standard preparations for colonoscopy, while three trials (177 patients) have studied surgical patients. After evaluating patient tolerance, quality of colonic cleansing, and changes in microflora and colonic gas, GoLYTELY was found to be safe, rapid, and effective. It is well tolerated by patients and may become the preferred method of bowel cleansing.

Safety and efficacy of metallic stents in the management of colorectal obstruction

Background: The use of self-expandable metallic stents in the management of obstructing colorectal cancer has been described with increasing frequency in the literature. Our goal was to evaluate the efficacy and associated morbidity of the use of self-expandable metallic stents to relieve colorectal obstruction at our institution. Methods: A retrospective chart review of patients who underwent colorectal stent placement between December 2001 and December 2003 in a tertiary referral center was performed. Results: Stents were placed successfully in 17 of 21 patients (81%) with colorectal obstruction. Placement was achieved endoscopically in 13 patients and radiologically in 4. Ten self-expandable metallic stents were used as a bridge to surgery, and 7 were used for palliation. The obstructions were located in the sigmoid colon (11 patients), the rectosigmoid (3), the splenic flexure, the hepatic flexure, and the rectum. Malignant obstruction was noted in 14 patients. One patient with malignancy experienced a sigmoid perforation, and 2 patients with benign disease had complications (1 stent migration and 1 re-obstruction). Stent patency in obstruction secondary to colonic adenocarcinoma was 100% in our follow-up period (range, 5 to 15 months). Conclusions: The use of stents as a bridge to surgery is associated with low morbidity, allows for bowel preparation, and thus avoids the need for a temporary colostomy. Long-term patency suggests that stents may allow for the avoidance of an operation in patients with metastatic disease and further defines their role in the palliation of malignant obstruction. Further prospective randomized studies are necessary to fully elucidate the use of stents in the management of colorectal cancer.

Portal Hypertensive Gastropathy

Portal hypertensive gastropathy (PHG) is part of a complex syndrome which occurs as a complication of chronic liver disease and portal hypertension (PHTN). At endoscopy, the gastric mucosa shows that mosaic-like pattern and red marks, which are the source of gastric bleeding. Only the severe form of gastropathy is liable to bleed. The pathogenesis of PHG and the hemodynamic changes in PHTN are not completely understood, but chronic increase in portal pressure is a prerequisite for the development of this disorder. It has been suggested that an overproduction of endogenous vasodilators and a reduced vascular sensitivity to endogenous vasoconstrictors contribute to these circulatory disturbances. H2 receptor antagonists and sucralfate are ineffective in the management of bleeding PHG. Two small studies reported that propranolol is effective in arresting mucosal hemorrhage from severe PHG. Other feasible alternatives include transjugular intrahepatic portal-systemic shunt (TIPS) and portal-systemic shunt procedure.

Secretin provocation in normal and duodenal ulcer subjects. Is the gastrin rise in Zollinger-Ellison syndrome paradoxic or exaggeration?

The secretin provocation test for gastrinoma is based on the premise that secretin decreases or has no effect on serum gastrin in normal and duodenal ulcer subjects while inducing a paradoxical rise in gastrinoma. We reexamined the serum gastrin response to pharmacologic amounts of secretin in normal volunteers (N=17) and unoperated duodenal ulcer patients (N=10). GIH secretin caused significant early gastrin rises from baseline in both groups (P<0.05). The gastrin response curves after secretin were not significantly different between normal and ulcer subjects. Similar gastrin rises were seen when synthetic secretin was administered to normal subjects (N=6). In normal volunteers, intravenous bolus saline (N=10) or amino acid (l-cysteine,N=8) caused no change in serum gastrin from baseline. The gastrin response curves to GIH secretin and saline were significantly different (P<0.05). Our findings suggest that the gastrin rise in gastrinoma patients after secretin is an exaggeration of the normal response and not paradoxical.

X-ray-negative Dysphagia: Is Endoscopy Necessary?

We reviewed our experience with patients with symptoms of dysphagia to determine whether endoscopy increased the chance of finding esophageal carcinoma when barium studies of the esophagus were normal. Endoscopy reports from 1974 to 1982 identified 195 patients with x-ray-negative dysphagia. In no patient was esophageal carcinoma found endoscopically. When patients with hiatal hernia (22) or endoscopic Grade I or II esophagitis (52) were excluded, only eight patients were found to have an endoscopic abnormality not demonstrated previously by x-ray. In addition, 56 cases of esophageal carcinoma seen at our institution over the same period all showed abnormal barium esophagrams at the time of presentation. We conclude that endoscopy to exclude esophageal carcinoma in patients with dysphagia is not as necessary as claimed, at least when adequate barium studies of the esophagus are normal.