David S. Kaplan

Effect of transjugular intrahepatic portosystemic shunt on secondary hypersplenism

BACKGROUNDnPortal hypertension is frequently associated with secondary hypersplenism, two common clinical manifestations of which are leukopenia and thrombocytopenia. Surgical portosystemic shunts alleviate portal hypertension but their effect on hypersplenism remains unpredictable. Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure for portal decompression. From current reports it is not clear if TIPS improves hypersplenism in patients with portal hypertension. We present a retrospective review of our experience with TIPS to determine the effect on hypersplenism.nnnPATIENTS AND METHODSnSixty-five patients who had a TIPS procedure between December 1991 and June 1994 were evaluated retrospectively. The records were specifically reviewed for platelet and white blood cell counts performed before the procedure, within a week after the procedure, and then again within the subsequent 3 weeks. Hypersplenism was defined as thrombocytopenia (platelet count of <100,000/mm3), leukopenia (white blood cell count of <5,000/mm3), or both.nnnRESULTSnThrombocytopenia alone was present in 33 patients and leukopenia alone in 4 patients before TIPS was performed. Both leukopenia and thrombocytopenia were present in 12 individuals. At least one of these indices of hypersplenism was present in 49 patients. Leukocyte count improved in 11 of 16 patients (69%) whereas platelet count improved in 34 of 45 patients (75%) within a week of the procedure. In the subsequent 3 weeks, leukopenia was relieved in 5 of 10 patients (50%) and thrombocytopenia in 21 of 28 patients (75%), respectively. Of the 12 patients who had both leukopenia and thrombocytopenia before TIPS, the indices improved in 4 patients (33%) within a week of the procedure. Thrombocytopenia was more consistently corrected as opposed to leukopenia, albeit in the short term.nnnCONCLUSIONnThe TIPS procedure is a promising, minimally invasive method of portal decompression that is effective in the treatment of complications of portal hypertension including secondary hypersplenism.

Expandable metal stents in achalasia - Is there a role?

Abstract OBJECTIVE: Achalasia is treated with pneumatic dilation or myotomy, and botulinum toxin injections are occasionally used. We review our community’s experience with expandable metal stents in six patients who failed medical treatment or were poor surgical candidates. METHODS: Eight stents were placed in six patients between July 1995 and November 1997. Four patients had achalasia and two pseudoachalasia. Four patients underwent successive botulinum toxin injections. One patient only agreed to periodic Maloney dilatations or a stent. Pneumatic dilation was performed in one patient and considered high risk in the rest. All were poor surgical candidates. Three different stents were used: Gianturco Rosch Z stent, Wallstent I, and Wallstent II. RESULTS: One-month mortality and morbidity were 33% and 50%, respectively. Two patients were asymptomatic on a liquid diet for ≥6 months but required repeat endoscopy for recurrent dysphagia because of food bolus impaction and proximal stent migration in each. CONCLUSIONS: Expandable metal stents in achalasia or pseudoachalasia do not provide sustained symptom relief, and their use is associated with unacceptably high morbidity and mortality. We do not recommend the use of these devices in patients who have failed medical therapy or who are poor surgical candidates.

Irritable Bowel syndrome (IBS) and alcohol abuse or dependence

Irritable bowel syndrome (IBS) has been reported in 10-22% of adults. Using a semistructured clinical interview to study the prevalence of IBS, we compared 31 patients seeking treatment for alcohol abuse or dependence in an outpatient setting with an age- and sex-matched control group of 40 patients who were seeking treatment in a general physicians office for other medical illnesses. The control group did not have any Axis I disorders. IBS was diagnosed according to the criteria of Drossman et al. Thirteen (41.9%) patients with alcohol abuse or dependence met the criteria for IBS, in contrast to 1 (2.5%) patient in the control group. We conclude that IBS is common and frequently underdiagnosed in patients with alcohol abuse or dependence.

Expandable metal stents in achalasia|[mdash]|is there a role|[quest]|

OBJECTIVE:Achalasia is treated with pneumatic dilation or myotomy, and botulinum toxin injections are occasionally used. We review our communitys experience with expandable metal stents in six patients who failed medical treatment or were poor surgical candidates.METHODS:Eight stents were placed in six patients between July 1995 and November 1997. Four patients had achalasia and two pseudoachalasia. Four patients underwent successive botulinum toxin injections. One patient only agreed to periodic Maloney dilatations or a stent. Pneumatic dilation was performed in one patient and considered high risk in the rest. All were poor surgical candidates. Three different stents were used: Gianturco Rosch Z stent, Wallstent I, and Wallstent II.RESULTS:One-month mortality and morbidity were 33% and 50%, respectively. Two patients were asymptomatic on a liquid diet for ≥6 months but required repeat endoscopy for recurrent dysphagia because of food bolus impaction and proximal stent migration in each.CONCLUSIONS:Expandable metal stents in achalasia or pseudoachalasia do not provide sustained symptom relief, and their use is associated with unacceptably high morbidity and mortality. We do not recommend the use of these devices in patients who have failed medical therapy or who are poor surgical candidates.

Use of a Mouth Gag Instrument to Facilitate Bite Block Insertion and Prevent Finger and Probe Bites During Transesophageal Echocardiography

Transesophageal echocardiography greatly enhances the examination of patients difficult to image transthoracically. While of low patient risk, a potential for harm from human bites to the echocardiography staff and to the transesophageal probe remains, particularly when dealing with uncooperative patients. This risk potential prompted implementation of additional anti‐bite protection in our universal precautions policy beyond use of a standard mouth guard. A mouth gag instrument was modified by placing latex rubber tubing over the instrument blades. This instrument was inserted into the mouth and set in an open position giving the operator safe access for probe and mouth bite guard insertion. This technique improved access to the patients mouth and visualization of probe insertion without the mouth bite guard. The mouth gag instrument provided an insertion of the transesophageal probe in impaired or otherwise uncooperative patients, which was safer for the patient, laboratory staff, and the probe itself.