Edward T. Stewart

Movement of the Feline Esophagus Associated with Respiration and Peristalsis. AN EVALUATION USING TANTALUM MARKERS

The outer, lateral esophageal walls in the distal half of the esophagus in each of five cats were labeled with small tantalum wires. About 8 wk later, esophageal motion associated with respiration and peristalsis, induced by injecting barium boli (5 ml each) into the proximal esophagus, was recorded on cine and serial biplane roentgenograms while recording intraluminal esophageal pressures simultaneously by manometry. Esophageal motion was also evaluated without a manometric tube in place. The coordinates for each marker were digitized and a computer was used to plot marker position against time. During respiration, the markers passively made a shallow, 2-10 mm excursion on the longitudinal esophageal axis. This movement was synchronous with thoracic and diaphragmatic movement and changes in intraluminal esophageal pressure. Immediately after the onset of peristalsis, the markers made a pronounced oral movement of 10 mm or more above their mean respiratory position, as if to engulf the bolus. Markers in opposing esophageal walls approximated one another and commenced an aboral movement as the bolus tail, which was essentially co-incident with onset of the manometric pressure complex, passed the marker sites. The markers returned to their respective rest positions essentially coincident with passage of the pressure complex peak and then moved below their respective rest positions. The aboral excursion occurred predominantly after the bolus had emptied into the stomach. The magnitude and duration of oral excursion was significantly greater for the distal than for the more proximal markers; conversely, the magnitude and duration of aboral excursion was greater for the proximal than for the more distal markers. During the peristaltic sequence, the labeled portion of the esophagus shortened from 26 to 46% of its resting length. No evidence of esophageal torque was shown. These findings suggest that both the longitudinal and circular esophageal musculature play an active and important role during peristaltic transport of a bolus through the esophagus.

Role of Endoscopic Retrograde Cholangiopancreatography in the Diagnosis and Treatment of Choledochocele

Choledochocele is a rare abnormality involving the intramural segment of the common bile duct. It may present clinically as recurrent acute pancreatitis, biliary colic, or cholestatic jaundice. A choledochocele may be easily overlooked by the conventional diagnostic methods, such as upper gastrointestinal series, intravenous cholangiogram, abdominal ultrasound, and computed tomography. Endoscopic retrograde cholangiopancreatography is helpful in demonstrating a choledochocele. Additionally, in selected cases, a choledochocele may be effectively managed by endoscopic sphincterotomy. We present the clinical, endoscopic, and radiographic findings in a series of 8 patients with choledochocele. The radiologic technique most useful in demonstrating a choledochocele at the time of endoscopic retrograde cholangiopancreatography is detailed. The pathogenesis, differential diagnosis, and relevant current literature pertaining to choledochocele are discussed.

Biliary and pancreatic duct pressures measured by ERCP manometry in patients with suspected papillary stenosis

Papillary stenosis is an imprecisely defined clinical syndrome which eludes definitive diagnosis. In this study we evaluated 26 patients with suspected papillary stenosis by manometric examination of the sphincter of Oddi done during ERCP examination. Basal pressure in the sphincter of Oddi was elevated in 14 of the patients. Of these 14 patients, 10 underwent sphincterotomy and all experienced improvement in clinical symptoms after their surgery. We suggest that ERCP manometry is a useful procedure for identifying patients with papillary stenosis who may benefit from sphincterotomy.

Endoscopic retrograde cholangiopancreatography in children

Endoscopic retrograde cholangiopancreatography (ERCP) is a universally used diagnostic and therapeutic modality in adults with pancreaticobiliary tract disease; its use in children with similar problems has been limited. We have performed ERCP procedures in 39 children and adolescents (aged 6 months to 18 years; mean 12.5 years), using the standard adult and pediatric side-viewing endoscopes. In selected cases, ERCP manometric study of the sphincter of Oddi, endoscopic sphincterotomy, or balloon extraction of common bile duct stones was performed. Nineteen patients had significant or abnormal structural findings, including pancreas divisum (four patients); sclerosing cholangitis (three); and choledochal cyst, chronic pancreatitis, choledochocele, pancreatic pseudocyst, common bile duct stone, and sphincter of Oddi motor dysfunction (two each). In all instances in which patients required operation, ERCP examination provided specific anatomic detail that was useful for planning appropriate intervention. The only significant complication after ERCP was mild pancreatitis, which occurred in four patients and responded to supportive, short-term measures.

Efficacy of Quantitative Hepatobiliary Scintigraphy and Fatty-Meal Sonography for Evaluating Patients With Suspected Partial Common Duct Obstruction

In this study we evaluated by blinded design the diagnostic efficacy of two noninvasive techniques, quantitative hepatobiliary scintigraphy (QHS) and fatty-meal sonography (FMS), for evaluating patients with suspected partial common duct obstruction. Quantitative hepatobiliary scintigraphy was performed on 56 cholecystectomized individuals (22 asymptomatic controls, 28 patients with suspected partial common duct obstruction, and 6 nonjaundiced cirrhotics) and FMS was done in 51 cases. For QHS, time-activity curves were generated for regions of interest over the liver, hepatic hilum, and common duct. For FMS, we measured common duct diameter before and 45 min after a fatty meal (Lipomul, 1.5 ml/kg). Each of the 28 patients with suspected partial common duct obstruction and 6 cirrhotic patients underwent endoscopic retrograde cholangiography, often accompanied by sphincter of Oddi manometry. Findings from these examinations were taken as the gold standard to determine the presence or absence of conditions that could account for intermittent symptomatic partial common duct obstruction. The most sensitive indicators for a positive test were a 45-min isotope clearance of less than 63% for QHS and a common duct increase of greater than or equal to 2 mm after the fatty meal for FMS. Of 28 patients with suspected partial common duct obstruction, 15 were judged to be true-positive and 13 true-negative. The 6 cirrhotic patients were without common duct obstruction. The study findings showed that each test had a 67% sensitivity that improved to 80% when the findings from both test results were combined. The specificity of QHS was 85% and that of FMS was 100%. All 6 cirrhotic patients had negative findings on FMS and 4 were false-positive on QHS. The true-positives included 8 patients with a small common duct stone and 6 with obstructive sphincter of Oddi dysfunction (4 stenosis, 2 dyskinesia). We conclude that noninvasive QHS and FMS afford good sensitivity and specificity for evaluating cholecystectomized patients with suspected partial common duct obstruction.

Computed tomography, ultrasonography, and endoscopic retrograde cholangiopancreatography in the diagnosis of pancreatic disease: A comparative study

A prospective study was performed comparing the sensitivity of computed tomography, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pancreatic disease. Forty patients with suspected pancreatic carcinoma, acute recurrent or chronic pancreatitis, and/ or jaundice were studied. CT was the most sensitive study in evaluation of pancreatitis. ERCP was most accurate in evaluation of pancreatic malignancy. Ultrasonography was the least sensitive method in detecting pancreatic disease and dilatation of the extrahepatic biliary ducts.

A comparison of colonoscopy and roentgenography for detecting polypoid lesions of the colon.

This study compares the effectiveness of the roentgen and colonoscopic examination of the colon for detecting polypoid lesions. We evaluated the findings in 64 patients with suspected or known polypoid lesions who received the same colon cleansing regimen for both examinations, and were studied by examiners of similar expertise. As in other studies, the endoscopist had the advantage of knowing the roentgen findings, and the colonoscopic findings were often taken to indicate whether or not a lesion was present. In about half the patients, however, a second roentgen examination, repeat colonoscopy, or surgical specimen provided additional information for scoring. For example, a filling defect of the same size and location on two roentgen examinations, but not demonstrated at colonoscopy was scored as a false negative colonoscopic finding.The study results indicate that 54% of small polyps ≦0.9 cm in size were missed on roentgen examination, whereas no proven misses for lesions of this size were shown for colonoscopy. This absence of colonoscopic false-negative findings for small polyps, however, may be partially explained by a relative insensitivity of the roentgen method. For larger lesions ≧1.0 cm in size the miss-rate for the two examinations was similar: 15% for roentgen examination and 12% for colonoscopy.We conclude: (1) Colonoscopy is a more sensitive method than roentgen examination for detecting small polyps of the colon, and (2) Performance of the two examinations may be comparable for demonstrating lesions 1.0 cm or larger in size.

Selective use of esophageal manometry and 24-Hour pH monitoring before laparoscopic fundoplication.

BACKGROUND Preoperative esophageal manometry and 24-hour pH monitoring commonly are used in preoperative evaluation of patients undergoing fundoplication. Here we review our experience with the selective preoperative workup of patients undergoing fundoplication to treat gastroesophageal reflux disease. STUDY DESIGN A series of 628 consecutive antireflux procedures was reviewed. History and physical examination, upper endoscopy, and upper gastrointestinal videofluoroscopy were obtained preoperatively on all patients; the first 30 patients also underwent esophageal manometry and pH monitoring (routine evaluation group). Thereafter, pH monitoring only was performed for atypical reflux symptoms, and manometry only was performed for a history of dysphagia, odynophagia, or for abnormal motility on videofluoroscopy (selective evaluation group). All patients underwent a laparoscopic floppy Nissen fundoplication, and then endoscopy and fluoroscopy at 3 months and 12 months postoperatively. RESULTS Eighty-five of the patients in the selective evaluation group (14%) required manometry, and 88 (15%) underwent pH monitoring. Eighteen of the 115 patients who underwent manometry (16%) had evidence of dysmotility. None of these 18 patients had increased dysphagia postoperatively; 8 of 18 reported improvement with swallowing. Five patients in the selective group (0.8%) had persistent postoperative dysphagia caused by technical error (four patients) or with no identifiable cause (one patient). The estimated charge or collection reduction with use of the selective evaluation was 1,253,100 US dollars or 395,000 US dollars, respectively. CONCLUSIONS Selective use of manometry and pH monitoring was cost effective and safe in this series. Although esophageal manometry and 24-hour pH monitoring might be necessary with abnormal findings on videofluoroscopy or atypical symptoms, in our experience, their routine use is not essential in preoperative evaluation of patients undergoing fundoplication for gastroesophageal reflux disease.

A prospective analysis of fever and bacteremia following ERCP.

Temperature elevations were found to occur in 20% of patients undergoing ERCP. Bacteremia accounted for only one-third of febrile episodes and occurred at about the same frequency as reported in upper gastrointestinal endoscopy. The endoscope and infected papillary fluid were sources of bacteremia documented. Nearly all patients with bacteremia had partial obstruction of the pancreaticobiliary tract.

Alimentary tract lesions in Cowden's disease

Cowdens disease was first recognized by its striking dermatological manifestations and subsequently by the increased incidence of neoplastic involvement of the thyroid and breast. Two cases of Cowdens disease with gastrointestinal polyps are presented to illustrate the alimentary tract involvement in this syndrome, gastrointestinal tract involvement with polyposis being seen in at least 50% of cases. As opposed to the more serious potential of neoplasia in the thyroid and breast, involvement of the alimentary tract has negligible clinical impact to the patient.