Choichi Sugawa

Complications associated with esophagogastroduodenoscopy and with esophageal dilation

Complications associated with esophagogastroduodenoscopy and with esophageal dilation Paul Mandelstam, MD Lexington, Kentucky Choichi Sugawa MD Detroit, Michigan Stephen E. Silvis, MD Minneapolis, Minnesota Otto T. Nebel, MD Solana Beach, California B. H. Gerald Rogers, MD Chicago, Illinois Among 211,410 peroral endoscopic examinations reported in a survey of AISIGIE members, the overall rate of complications was 1.32/1000. The complication rates for esophageal dilation ranged from 4.25 to 18.4/1000, depending on the technique employed. Major complications included perforation, hemorrhage from biopsy, aspiration, myocardial infarction, cardiac arrest and arrhythmia, and respiratory arrest attributed to topical pharyngeal anesthesia or intravenously administered diazepam (Valium). While confirming the prevailing safety of peroral endoscopy and dilation, this survey points up the need for unremitting vigilance. Radiographic examination, when feasible, should precede peroral endoscopy. Any suspicion of perforation requires prompt radiologic investigation using a water-soluble contrast medium. Biopsy at the base of an ulcer is hazardous. Cardiopulmonary resuscitation should be immediately available in the endoscopy room. Pneumatic dilation of the esophagus carries a small but definite risk of rupture which necessitates emergency thoracotomy.

Complications of flexible fiberoptic colonoscopy and polypectomy

The results of the 1974 A/S/G/E survey of complications relating to colonoscopy and polypectomy are analyzed. Members reported 25,298 diagnostic colonoscopies with a morbidity of 0.32% and a mortality of 0.008%. The most common complication of diagnostic colonoscopy was perforation (55 cases or 0.22%). The only fatalities (2) were associated with perforation. There were 6,214 colonoscopic polypectomies reported with a morbidity of 2.3% and no mortality. The most common complication of polypectomy was hemorrhage (115 cases or 1.9%).

Mallory-Weiss syndrome: A study of 224 patients☆

With the increasing early use of endoscopy, Mallory-Weiss syndrome has been found to be the cause of upper gastrointestinal bleeding in 224 of 2,175 (10.3 percent) patients studied. Since Mallory-Weiss syndrome is a self-limiting disease in more than 90 percent of patients, conservative treatment, including multiple transfusion, electrocoagulation, and compression by a Sengstaken-Blakemore tube in descending order of use, is the treatment of choice, especially in the medically debilitated patient. The cirrhotic patient poses special difficulty and generally has a poor outcome no matter what the treatment. Prolapse of the stomach into the esophagus may be an etiologic factor in a small subgroup of patients.

Upper GI bleeding in an urban hospital: Etiology, recurrence, and prognosis

Acute upper gastrointestinal bleeding (UGIB) continues to be a common cause of hospital admission and morbidity and mortality. This study reviews 469 patients admitted to a surgical service of an urban hospital. There were 562 total admissions because 53 patients were readmitted 93 times (recurrence rate, 20%). The most common causes of bleeding, all endoscopically diagnosed, included acute gastric mucosal lesion (AGML) (135 patients, 24%), esophageal varices (EV) (121 patients, 22%), gastric ulcer (108 patients, 19%), duodenal ulcer (78 patients, 14%), Mallory-Weiss tear (61 patients, 11%), and esophagitis (15 patients, 3%). Nonoperative therapy was sufficient in 504 cases (89.5%). Endoscopic treatment was used in 144 cases. Operations were performed in 58 cases (10.5%), including 29% of ulcers. Emergency operations to control hemorrhage were required in only 2.5% of all cases. The rate of major surgical complications was 11% and the mortality rate was 5.2%. There were 58 deaths (12.6%), with 36 deaths directly attributable to UGIB. Factors correlating with death include shock at admission (systolic blood pressure less than 80), transfusion requirement of more than five units, and presence of EV (all p less than 0.001). Most cases of UGIB can be treated without operation, including endoscopic treatment, when diagnostic endoscopy establishes the source. Subsequent operation in selected patients can be done with low morbidity and mortality rates.

Identification of Helicobacter pylori biofilms in human gastric mucosa.

The purpose of this study was to use endoscopically directed biopsies and scanning electron microscopy (SEM) to document the existence of Helicobacter pylori biofilms in human gastric mucosa. Patients underwent flexible esophagogastroduodenoscopies with three gastric mucosal biopsies. Rapid urease testing was performed to determine the presence or absence of H pylori. Urease-positive and urease-negative control specimens were imaged with SEM to obtain detailed images of gastric mucosa for the identification of biofilm colonies. Samples were obtained from patients who underwent esophagogastroduodenoscopies. Eleven were found to be H pylori positive and nine were H pylori negative. These were imaged at 50O × and 1000 × with electron microscopy. Dense, mature biofilms were present and attached to the cell surface of H pylori-positive specimens and were absent in urease-negative controls. Photomicrographs were obtained. Biofilms are complex microbiological ecosystems where sessile bacteria surround themselves in a protective matrix. This lifestyle affords protection, allows for growth in hostile environments, and alters host physiology. Many have hypothesized that H pylori infections resulting in gastric ulcers may be a manifestation of biofilms. Our investigation is the first to photographically document the existence of H pylori biofilms on human gastric mucosa. This elucidation of the ecology and pathophysiology of the mucosa of the organism is important to our understanding of a potential mechanism of this organism’s resistance to current therapy and how to better eradicate it in the future.

Pancreas divisum: Is it a normal anatomic variant?

One thousand five hundred twenty-nine pancreatograms were obtained between 1973 and 1985. Complete pancreas divisum was demonstrated in 41 patients, for an incidence of 2.7 percent, and incomplete pancreas divisum in 14 cases, for an incidence of 0.9 percent. No increased incidence of pancreas divisum was found in any of four groups: an incidental group, a group with alcoholic pancreatitis, a group with unexplained upper abdominal pain, and an idiopathic pancreatitis group. The majority of patients (80 percent) were found to have pancreas divisum as an incidental finding or in association with alcoholic pancreatitis. Of 82 patients with idiopathic pancreatitis, only 2 had pancreas divisum. The three patients with pancreas divisum who had sphincteroplasty of the minor papilla were not helped by the procedure. We conclude that pancreas divisum is a normal anatomic variant and is very seldom a cause of pancreatic pain.

Acute lower gastrointestinal bleeding in 1,112 patients admitted to an urban emergency medical center.

BACKGROUND This study was performed to elucidate the etiology, effectiveness of diagnostic and therapeutic modalities, and outcomes in patients with acute lower gastrointestinal bleeding. METHODS A retrospective review of the medical records of 1,112 consecutive patients admitted to the surgical service of a single urban emergency hospital with lower gastrointestinal bleeding from 1988 to 2006. Two groups were compared: 1988-1997 and 1998-2006. RESULTS All patients underwent colonoscopy, 33.2% within 24 h of admission. Hematochezia was the most frequent presentation (55.5%), followed by maroon stool (16.7%) and melena (11.0%). Most patients, 690 (62.1%) also had upper endoscopy. Sixty-six patients subsequently had barium enemas. Eleven of 27 nuclide scans were positive. Arteriography was performed on 22 patients, with 11 positive results and 2 therapeutic. No statistical difference was found in procedures performed in our 2 time periods. Diverticulosis (33.5%), hemorrhoids (22.5%), and carcinoma (12.7%) were the most common etiologies with the diagnosis of diverticulosis more common in the 1998-2006 time period. The small bowel was the source in 14 total patients. Spontaneous cessation of the bleeding occurred in 863 (77.6%) patients. Endoscopic control increased from 1% in 1997-1998 to 4.4% in 1998-2006 (P < .05) with a corresponding decrease in the need for operative control from 22.6% to 16.6% in this same time period (P < .05). Furthermore, among elective operations, there was a decrease in right hemicolectomies from 31.6% of total elective cases to 13.9% (P < .05). Emergent operations were needed in 3.4% and 4.8% of patients. The readmission rate did not change over time and was 5.2% overall with >50% because of diverticular bleeding. CONCLUSION In this urban setting, diverticulosis, hemorrhoids, and carcinoma were the most common causes of severe acute lower gastrointestinal bleeding (LGIB) with diverticular bleed causing the highest recurrence. Colonoscopy allows for diagnosis in most patients with severe acute LGIB requiring hospitalization. Furthermore, it is now being used more effectively for hemostasis resulting in less operative intervention to control bleeding.

Presence and density of Helicobacter pylori biofilms in human gastric mucosa in patients with peptic ulcer disease

Our purpose was to use endoscopically directed biopsies and scanning electron microscopy to quantify Helicobacter pylori biofilm density on the surface of human gastric mucosa in urease-positive and -negative patients. Participating patients underwent flexible esophagogastroduodenoscopies coupled with gastric mucosal biopsies. Rapid urease testing was performed on all specimens to determine the presence of H. pylori, followed by scanning electron microscopy to identify the existence of biofilms. Samples were then analyzed using Carnoy Image Analysis Software to determine percent biofilm coverage of the total surface area. These data were compared to control specimens that were urease negative. Of the patients who tested urease positive for H. pylori, the average percent of total surface area covered by biofilms was 97.3%. Those testing negative had an average surface area coverage of only 1.64%. These differences were determined to be statistically significant at the 0.0001 level. This study demonstrates that compared with controls, urease-positive specimens have significant biofilm formation, whereas urease-negative specimens have little to none. This was reflected in the significantly increased biofilm surface density in urease positive specimens compared with urease-negative controls.

Lower gastrointestinal bleeding: a review

Lower gastrointestinal bleeding (LGIB) continues to be a problem for physicians. Acute LGIB is defined as bleeding that emanates from a source distal to the ligament of Treitz. Although 80% of all LGIB will stop spontaneously, the identification of the bleeding source remains challenging and rebleeding can occur in 25% of cases. Some patients with severe hematochezia require urgent attention to minimize further bleeding and complications. This article reviews the causes, diagnostic methods, and endoscopic treatment of LGIB.

Clinical evaluation and management of caustic injury in the upper gastrointestinal tract in 95 adult patients in an urban medical center

BackgroundCaustic ingestion causes a wide spectrum of injuries; appropriate treatment varies according to the severity and extent of the injury. This retrospective study of adult patients with caustic injury presents the endoscopic findings, treatment regimen, and clinical outcome.MethodsOver a 28-year period, 95 consecutive adult patients admitted to an urban emergency hospital for ingestion of caustic materials were studied. Each patient underwent early endoscopy and the injury was graded for severity. There were 61 men and 34 women with an average age of 37.2 years (range 17 to 81). Ingestion was due to a suicide attempt in 49 patients and accidental in 46 patients.ResultsTen patients showed no mucosal damage. The remaining 85 patients had grade I superficial injury in 47 patients, grade II moderate injury in 25 patients, and deep grade III injury in 13 patients. The ingestion of strong acid or strong alkali often produced deep grade III changes while bleach, detergent, ammonia or other substances usually caused grade I injury. Operative interventions were required for 11 patients with grade III injury and 6 patients with grade II injury. Endoscopic grading was predictive for the onset of complications including late esophageal stricture. There were no complications due to endoscopy; one patient with grade III and multiple comorbidities died from multiple organ failure.ConclusionUpper gastrointestinal endoscopy after caustic ingestion should be performed early to define the extent of injury and guide appropriate therapy. Grade I injuries heal spontaneously. Grade II injuries may be treated conservatively but repeat endoscopy helps define when intervention is needed. Grade III injuries ultimately require surgical intervention.