David Katz

Benign air dissection of the esophagus and stomach at fiberesophagoscopy.

Three cases aptly illustrate a significant complication of esophagogastroscopy employing air insufflation. Probable mechanisms are considered, and remedies are proposed.

Sources of bleeding in upper gastrointestinal hemorrhage: A re-evaluation

SummaryTwo hundred fifty consecutive patients admitted for upper gastrointestinal hemorrhage were examined by endoscopy within 24 hr. of admission. The technic proved safe and was tolerated well. One hundred twenty-seven diagnoses (50.8%) were established by endoscopy alone. The incidence of duodenal ulcer (20%) as the bleeding source was strikingly below the figure usually quoted. Erosive gastritis and esophageal varices were the bleeding sources in 20% and 17.2% respectively, while 22% remained undiagnosed.

The endoscopic diagnosis of upper-gastrointestinal hemorrhage. Changing concepts of etiology and management.

In 1961, the gastroenterology group at Metropolitan Hospital in New York City embarked on its program of early endoscopy in the investigation of patients with acute upper-gastrointestinal bleeding (1). The more than 1400 consecutive endoscopic investigations represent the largest collection of this type from any one hospital in the United States (and probably in the world). Larger series of patients with hemorrhage from Great Britain (2, 3), accumulated over longer periods, have not utilized esophagoscopy routinely and have relied upon clinical diagnoses, while Palmer, who described the technique of early endoscopy in bleeders (4), has amassed a larger group than ours (5) from many institutions in over 20 years of work. It is our purpose at this time to evaluate the changes in concepts of etiology that have developed since the initiation of our study and the subsequent popularization of the technique. We would also like to touch upon some of our extensive experiences with acute mucosal lesions and the management of bleeding due to this entity.

The mallory-weiss syndrome: Evaluation by early endoscopy of its clinical picture and its incidence in upper gastrointestinal hemorrhage

Summary1. In a prospective study of upper gastrointestinal hemorrhage, 297 cases were examined endoscopically. Eight instances of gastric or esophageal tears were noted. Over the 29-month period during which the study was carried out, there were 49,760 admissions to this municipal teaching hospital. The incidence of gastroesophageal tears was 2.7% of all upper gastrointestinal bleeders and 0.016% of all admissions.2. Early endoscopy was of great value in establishing a rapid and accurate diagnosis of the lesion.3. In 2 instances bleeding did not result from the demonstrated tears, but was due to coexistent acute gastric erosions.4. In 4 other cases, bleeding from the tear stopped spontaneously; one of these was operated electively for a nonbleeding duodenal ulcer. Surgical intervention for continued bleeding was necessary in 2 patients, one of whom died.5. An initial conservative approach to therapy of the Mallory-Weiss syndrome is suggested, provided the diagnosis is ascertained by early esophagogastroscopy. Continued bleeding will obviously dictate surgical intervention.

EVALUATION OF ESOPHAGEAL VARICES IN LIVER DISEASE BY SPLENIC-PULP MANOMETRY, SPLENOPORTOGRAPHY, AND ESOPHAGOGASTROSCOPY; DIAGNOSTIC DISCREPANCIES.

Summary and ConclusionEsophagogastroscopy, splenic-pulp manometry, and splenoportography were combined in a prospective study of 60 patients with documented liver disease and suspected portal hypertension. All three procedures were performed on each of the patients within a 6-day period. Twenty patients were actively bleeding at the time of endoscopic examination.Esophagogastroscopy demonstrated varices in 90% of the patients studied. Splenoportography, however, demonstrated collateral circulation in only 50% of the patients with endoscopically demonstrated varices. In no instance did splenoportography demonstrate collateral circulation not previously seen on endoscopy. Splenoportography failed to demonstrate collateral circulation in all patients whose splenic-pulp pressure was less than 270 mm. water.In 20 patients with upper gastrointestinal bleeding, the height of the splenic-pulp pressure was a poor index of the site of bleeding. Eight patients with portal hypertension and esophageal varices were found to be bleeding from nonvariceal sites. Conversely, 5 patients with active bleeding from endoscopically demonstrated varices had no collateral circulation revealed by splenoportography.It is evident from this study that splenic-pulp manometry, splenoportography, and esophagogastroscopy will frequently yield divergent results in the evaluation of portal hypertension and portosystemic collateral circulation in patients with liver disease. While splenoportography may be useful in determining the patency of the portal vein and demonstrating large spontaneous or surgical portosystemic shunts, esophagogastroscopy is a better method for detecting esophageal varices and determining whether they are bleeding. The height of the splenic-pulp pressure is of little value in indicating the site of upper gastrointestinal bleeding.

Acute gastric mucosal lesions produced by augmented histamine test

Twenty patients were gastroscoped and subjected to suction biopsy of fundic mucosa under gastroscopic control before and after administration of augmented histamine stimulation preceded by an antihistamine.Prior to histamine administration, histologic changes diagnostic of erosive gastritis were noted in only 2 of 20 patients, and all gastroscopic examinations showed no erosions.Following the augmented histamine test, no overt hematemesis or melena has been noted in any of the patients. Of the 20 patients examined, severe mucosal hyperemia was seen on gastroscopic examination after histamine in 15, isolated acute gastric erosions in 10, diffuse erosions in 1, and overt intraluminal bleeding in 1. Significant histologic changes were noted 1/2–1 hr after histamine administration in gastric biopsy specimens. Of the 20 patients examined, 15 showed hemorrhage in the fundic neck and 17 in the lamina propria.The occurrence of erosions and mucosal hemorrhages was apparently not related to the acidity of the gastric secretion as these lesions were noted in patients with gastric anacidity and atrophic gastritis as well.

Endoscopy in upper gastrointestinal bleeding then and now: Changing concepts of bleeding sources

The authors compare their experience with endoscopy of gastrointestinal bleeders in the flexirigid era (1962) and the panendoscopic era (1972). They report a marked decrease in chronic duodenal ulcer and an increase in acute mucosal lesions as causes of bleeding. The number of undiagnosed cases remains disturbingly high (14%). Fiberoptic panendoscopy in bleeding patients is safe and well tolerated.

UPPER GASTROINTESTINAL BLEEDING IN THE AGED: A PROSPECTIVE STUDY UTILIZING A YOUNGER AGE GROUP AS CONTROL.

Summary1. Consecutive patients admitted for acute upper gastrointestinal bleeding were investigated by means of early esophagogastroscopy and upper gastrointestinal X-ray over a period exceeding 3 years. The series included 100 patients above the age of 60 and 181 below 60. 2. An acute gastric lesion (erosive gastritis or acute gastric ulcer) was the leading over-all source of bleeding in patients over and under 60 (27.0% and 24.8%, respectively). In nonmassive bleeding episodes, an acute gastric lesion was again the leading source in both groups (35.7% and 26.3%, respectively). 3. In massive bleeding, duodenal ulcer was the leading source in those over 60 (33.3%), while esophageal varices was the leading cause of bleeding in those below 60 (34.0%). 4. No statistically significant difference was noted in the severity of bleeding episodes in the over- and under-60 groups, nor was there any statistically significant difference in the over-all mortality of the 2 groups. 5. Early esophagogastroscopy was both safe and significant in establishing the sources of bleeding in the old age group.