David E. Fleischer

Endoscopic Perforations of the Upper Digestive Tract: A Review of Their Pathogenesis, Prevention, and Management

T he rapid and widespread increase of upper endoscopic esophagogastroduodenoscopy (EGD) in the last two decades is a tribute not only to the unparalleled access this procedure provides to the upper gastrointestinal tract but also to its excellent safety record.’ Nevertheless, complications do occur, occasionally with disastrous results. Familiarity with these risks of endoscopy is essential for their prevention and management. Many of the published reviews of endoscopic complications have been simple compilations of statistical data.‘-” The aim of this review is to bring together current concepts regarding the pathogenesis, management, and prevention of perforation of the upper digestive tract, with particular emphasis on esophageal injury. Diagnostic upper gastrointestinal endoscopy is an extremely safe procedure, with an overall complication rate in the range of 0.1% and a mortality rate of <0.005% reported by different centers worldwide.97’0~‘2 Perforation of a hollow viscus, although not common, is the most dreaded complication of endoscopy. The most common site of instrumental perforation during upper endoscopy is the esophagus, although gastric, duodenal, and other perforations have also been described.

The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated

BACKGROUNDnPeptic ulcer disease is considered the cause of upper-GI bleeding in 50% of cases. A recent decline in the proportion of cases of upper-GI bleeding because of a peptic ulcer was noted by us. The objectives of this study were to evaluate the frequency of peptic ulcer in patients with upper-GI bleeding and the proportion of bleeding peptic ulcers with a non-bleeding visible vessel.nnnMETHODSnPatients with upper-GI bleeding seen from December 1999 until April 2001 at a tertiary, university-affiliated medical center were studied prospectively. The Clinical Outcome Research Initiative (CORI) database was used to correlate the single institution data with nationwide data. Endoscopic data in the CORI database for patients who had endoscopy for upper-GI bleeding between December 1999 and July 2001 were retrieved and analyzed.nnnRESULTSnA total of 126 patients were included in the prospective study. The endoscopic findings were: peptic ulcer in 31.8%: 95% confidence interval (CI) [23.7%, 40.6%] of patients; a non-bleeding visible vessel was present in 10%: 95% CI[2.8%, 23.7%] of these peptic ulcers. From the nationwide CORI database, data for 7822 patients with upper-GI bleeding were obtained. The endoscopic findings were: peptic ulcer in 20.6%:95% CI[19.7%, 21.5%] of patients with upper-GI bleeding; a non-bleeding visible vessel was present in 7.3%: 95% CI[6.1%, 8.6%] of the ulcers.nnnCONCLUSIONSnThe frequency of peptic ulcer in patients with upper-GI bleeding and the proportion of bleeding ulcers with a non-bleeding visible vessel are less than previously reported.

Nonvariceal upper gastrointestinal bleeding

Nonvariceal upper gastrointestinal bleeding (NVUGIB) remains an important cause of morbidity and mortality. The etiological role and the relative risk of nonsteroidal anti-inflammatory drugs (NSAIDs) in association with other clinical factors are the focus of several papers published in the last year. Data from studies that evaluate the interaction of NSAIDs with Helicobacter pylori suggest that there is a clear role for eradication in aspirin-related bleeding. Although the benefit of H. pylori eradication in nonaspirin NSAID-related bleeding is being debated, they should both be eliminated given their relative contribution to the causation of peptic ulcer hemorrhage. The search for reliable and accurate tools to predict outcomes after NVUGIB continues. Recent important contributions in this area of research are the use of a clinical prediction guide to identify patients who are likely to require endoscopic intervention, and the use of Doppler ultrasound examination of the ulcer base to predict rebleeding. The role of antisecretory therapy in the setting of acute NVUGIB has been revisited in two meta-analyses and one randomized, placebo-controlled trial of omeprazole as an adjunct to endoscopic intervention. Until more definitive data are available, it appears that the effect of acid-decreasing medications is more important when endoscopic therapy is not provided than when effective endoscopic intervention is instituted. With regard to therapeutic endoscopy for upper gastrointestinal bleeding, the few randomized trials that have been published in full form in the last year focus on the use of mechanical methods of hemostasis for peptic ulcer bleeding and other etiologies such as Mallory-Weiss tears and Dieulafoy lesions.

Transesophageal Echocardiography: What the Gastroenterologist Thinks the Cardiologist Should Know About Endoscopy

Transesophageal echocardiography is becoming established as a very useful addition to cardiac ultrasound. Both the applications and the number of cardiologists using this technique are growing. This article is intended to assist the cardiologist by providing information about endoscopy, including the technique of intubation, medications for sedation, medicolegal aspects, concerns of health personnel, and other related aspects.

Endoscopic mucosal resection of the esophagus: band ligation technique.

Endoscopic mucosal resection (EMR) is a minimally invasive endoscopic technique used in treating superficial cancers of premalignant lesions in the gastrointestinal tract. An attraction of this technique is that it can be curative with low morbidity, often providing the entire lesion for pathologic evaluation. The band ligation technique of EMR uses the existing technology of variceal band ligation to endoscopically place a band on flat mucosal lesions of the gastrointestinal tract to create a pseudopolyp before resection with an electrocautery snare. The band ligating technique and two variant band ligating devices are described.

Gastrointestinal involvement in paroxysmal nocturnal hemoglobinuria: First report of electron microscopic findings

Thrombotic complications, particularly microthrombi involving intraabdominal veins leading to intestinal ischemia, have remained a major cause of morbidity in patients with paroxysmal nocturnal hemoglobinuria (PNH). While intestinal ischemia has been postulated to be the cause of recurrent bouts of abdominal pain in this population, direct antemortem evidence for this complication is scarcely documented in the literature. We describe a case of PNH in a patient who presented with abdominal distress three years after the initial diagnosis was established. Clinical features and a combination of diagnostic modalities, including radiography, endoscopy, and histology were used to make the prompt diagnosis of intestinal ischemia. This is the first case in which the electronic microscopy of the gastrointestinal lesion is described. Our patient was successfully treated with conservative measures and anticoagulation.

Laser therapy for malignant esophageal strictures

Laser therapy was the predominant form of endoscopic treatment for esophageal cancer in the 1980s and early 1990s. More recently, self-expanding metal stents are used more commonly for palliation. Laser treatment can be used as an adjunct to stent placement (to open the lumen to allow stent placement or to debride obstructed stents) or in some cases as primary treatment. The clinical results and technical details are discussed.

Segmental non-familial colonic polyposis

agents. In fact, patients with AIDS are unique because they may be affected by multiple simultaneous diseases and infections often difficult to discover. Immunodeficiency may be associated with the absence of reaction to the dissemination of a potentially lethal parasite such as Leishmania donovani, delaying effective treatment. Therefore, during an endoscopic procedure in a patient with AIDS, we recommend that, in addition to formaldehyde for light microscopy, some specimens should be fixed in glutaraldehyde for electron microscopy and others should be placed in suitable microbiological media to detect viruses, bacteria, fungal forms, and protozoa.