Eric M. Ward

Barrett's esophagus is common in older men and women undergoing screening colonoscopy regardless of reflux symptoms.

BACKGROUND:Although Barretts esophagus (BE) is the precursor of esophageal adenocarcinoma (ACA), most patients with ACA present outside of a BE surveillance program. This could be due to undiagnosed symptomatic GER and BE or BE/ACA occurring in patients without reflux symptoms. We have, therefore, studied the prevalence of BE and symptom status in older patients referred for colonoscopy.METHODSAll patients referred for outpatient colonoscopy were eligible if they were at least 65 yr old and had not previously undergone esophagoscopy. After informed consent, the patients completed detailed GER questionnaires. During the research endoscopy, the endoscopist recorded the squamocolumnar junction (SCJ) as either long-segment BE (LSBE), short-segment BE (SSBE), or normal. If the SCJ was felt to be “irregular” the endoscopist was asked to predict, in their judgment, if BE was present. All patients had biopsies below the SCJ, which were examined by a gastrointestinal pathologist who was blinded to the endoscopic findings.RESULTSBE esophagus was present in 50 of the 300 patients studied (16.7%). BE was more common in men (35 of 161, 21.7%) than in women (15 of 139, 10.8%) (p < 0.025). GERD symptoms were reported in 106 patients (35%) and BE was present in 19.8% of symptomatic and 14.9% of asymptomatic cases (NS). The majority of the BE in this study was less than 3 cm in length (92%). The questionnaires did not predict the presence of BE.CONCLUSIONSBE is common in unscreened male and female patients at least 65 yr of age who are referred for colonoscopy. Men were more likely than women to have BE although it occurred in both sexes. Reflux symptoms were fairly common but a poor predictor of BE.

Successful oesophageal pH monitoring with a catheter-free system.

Background : Traditional catheter‐based oesophageal pH testing is limited by patient discomfort and the tendency for patients to alter their diet and activities during the study. A catheter‐free pH monitoring system (Bravo) designed to avoid these problems has recently become available, but the advantages and limitations of this device have not been fully explored.

Prevalence and natural history of gastric antral vascular ectasia in patients undergoing orthotopic liver transplantation

Goals: To describe the prevalence and natural history of gastric antral vascular ectasia (GAVE) in patients with end-stage liver disease undergoing orthotopic liver transplantation (OLT). Background: GAVE is a well-recognized cause of gastrointestinal hemorrhage. Although 30% of patients with GAVE have liver disease, the prevalence of GAVE in patients with cirrhosis is not known. Study: We reviewed clinical records of patients who underwent OLT at our institution from February 1, 1998 to June 2003. Demographic and clinical details were recorded with attention to findings during upper endoscopy before and after OLT. Results: A total of 597 patients underwent OLT, and 345 were evaluated preoperatively with esophagogastroduodenoscopy (EGD). Eight (2.3%) were found to have GAVE before OLT. Three of these eight underwent EGD after OLT, and GAVE was absent in all three. None of the patients with GAVE experienced gastrointestinal bleeding postoperatively. Conclusions: GAVE was present in nearly 1 in 40 patients with end-stage liver disease who underwent EGD before OLT at our institution and appears to resolve after transplant. These findings are consistent with a previous report documenting resolution of GAVE after OLT.

Pharmacological management of Cronkhite-Canada syndrome

Cronkhite–Canada syndrome (CCS) is a rare, non-inherited gastrointestinal polyposis syndrome associated with characteristic ectodermal abnormalities. A number of potentially life-threatening complications including malnutrition, gastrointestinal bleeding and infection may occur in affected patients and CCS is fatal in many cases. The optimal therapy for CCS is not known but several treatment options have been described. Nutritional support, antibiotics, corticosteroids, anabolic steroids, histamine-receptor antagonists and surgical treatment have all been used with varying degrees of success. Unfortunately, controlled therapeutic trials have not been possible because of the rarity of the disease. Most recently, a combination regimen using histamine-receptor antagonists, cromolyn sodium, prednisone and suppressive antibiotics has been described. The reported treatment options and rates of success are reviewed.

Glucagon for the Relief of Esophageal Food Impaction Does It Really Work

We sought to evaluate our experience with glucagon used in the emergency department setting to relieve esophageal food impaction (EFI). We reviewed the records of patients with food impaction who received glucagon between January 1998 and May 2003 and recorded patient demographics, medical history, symptoms following glucagon administration, and endoscopic findings. There were 92 episodes of food impaction in 85 patients. Thirty-three percent of the episodes resulted in resolution of symptoms following a dose of glucagon. Sixty-seven percent had symptoms of food impaction after glucagon and underwent upper endoscopy in the emergency room. Only previous solid food dysphagia was positively associated with response to glucagon. Patients who received glucagon plus a benzodiazepine were more likely to have resolution of the EFI. In our experience, glucagon appears to relieve food impaction in one third of patients treated. This result is comparable to previously published data examining glucagon and placebo. The lack of advantage over placebo questions the practice of glucagon administration for EFI.

Symptoms do not predict the presence of Barrett’s esophagus in older patients undergoing colonoscopy

Symptoms do not predict the presence of Barretts esophagus in older patients undergoing colonoscopy

Vascular Ectasia of the Proximal Stomach

Gastric antral vascular ectasia (GAVE), also known as watermelon stomach, is a well-described cause of gastrointestinal hemorrhage first described by Rider et al. in 1953 [1]. Patients with GAVE may present with gross bleeding or asymptomatic iron deficiency anemia [2]. GAVE is readily diagnosed during upper endoscopy by the identification of characteristic antral mucosal abnormalities, most commonly linear columns of ectatic vessels converging in the pylorus. The lesions’ resemblance to the stripes of a watermelon led Jabbari et al. to coin the phrase “watermelon stomach,” which is commonly used by clinicians and endoscopists [3]. Histopathological confirmation is possible with biopsies of the gastric mucosa obtained during endoscopy, demonstrating dilated mucosal capillaries with fibrin thrombi and fibromuscular hyperplasia [4, 5]. The etiology of GAVE is not known, but a number of associated conditions have been reported. Up to 62% of patients with GAVE have connective tissue or autoimmune disease, including Raynaud’s phenomenon, hypothyroidism, diabetes

Diverticulum-associated colon mass due to Mu ̈llerian cyst: Detection by barium enema but not colonoscopy

VOLUME 53, NO. 3, 2001 GASTROINTESTINAL ENDOSCOPY 359 Intestinal lesions due to paratubal or Mullerian cysts have not been previously reported. Colonoscopy is often the procedure of choice for the detection of colonic neoplasms, but the accuracy of the procedure is dependent on the skill of the operator. Even expert colonoscopists can miss mass lesions in blind spots behind acute colonic bends or submucosal or extracolonic masses, which may be visible with barium enema.16-21 The presence of colonic diverticulosis can make the accurate detection of colon masses by barium enema and colonoscopy more difficult. There are reports of false-negative and false-positive results on barium enema and colonoscopy related to diverticulosis or diverticular disease.22-28 This is a report of a patient with a diverticulumassociated colonic mass lesion due to a Mullerian cyst that was discovered by barium enema, but not seen at sigmoidoscopy or 2 colonoscopies.

Watermelon herniopathy—a newly described variant of gastric antral vascular ectasia associated with Barrett's esophagus

Watermelon herniopathy—a newly described variant of gastric antral vascular ectasia associated with Barretts esophagus

Endoscopic Ultrasound (EUS) of the Esophageal Wall in Patients with Non Cardiac Chest Pain (NCCP)

Endoscopic Ultrasound (EUS) of the Esophageal Wall in Patients with Non Cardiac Chest Pain (NCCP) Eric M. Ward, Massimo Raimondo, Timothy A. Woodward, Sami R. Achem Background: The pathophysiology of NCCP is poorly understood. Recent studies using ultrasound miniprobes have noted thickened esophageal wall (EW) in selected patients. Whether conventional EUS is capable of recognizing these abnormalities has not been evaluated. Hypothesis: Patients with NCCP have abnormal submucosal EW that can be identified by conventional EUS examination. Purpose: Using standard EUS, to describe the characteristics of the EW in patients with NCCP. Methods: Computerized databases were used to identify patients withNCCPwho underwent esophageal motility testing andEUS. We reviewed both the clinical records of these patients and of patients without NCCP or esophageal disease who had also undergone EUS (control group). The EUS characteristics of the EW were analyzed. ANOVA and two-sample t-tests were used for statistical analysis. Results: 18 patients with NCCP and 8 control patients underwent EUS. Estimates of mean thickness of the EW at various locations andmanometry results are listed in the Table. There is a trend that nearly reaches statistical significance in EW thickness between the 4 groups at the distal esophagus (p=0.06); but none at the mid or proximal esophagus. Patients with diffuse esophageal spasms (DES) have thicker distal EW (mean 4.5mm) compared to controls (3.1mm, p=0.05). In addition, 4/6 patientswithDEShad thickening of the submucosal layer, a finding not present in any other group. Conclusions: This study suggest that standard EUS techniques are capable of recognizing a distinctive abnormality of the esophageal wall, particularly the submucosal layer, in patients with NCCP who have DES.