Eugene M. Bozymski

Principles of training in gastrointestinal endoscopy

1997-1998 James L. Achord, M.D., Chairman H. Worth Boyce, M.D. Steve Goodman, M.D. Frank Gress, M.D. Glenn W. W. Gross, M.D. Neil A. Jacobson, M.D. Stephen P. Martin, M.D. Paul Petersen, M.D. (TRAINEE) Francisco C. Ramirez, M.D. Choichi Sugawa, M.D. The American Society for Gastrointestinal Endoscopy publishes guidelines for training in gastrointestinal endoscopy to ensure optimal procedural training standards. The last guideline (1991)1 established threshold numbers at which competence could be subjectively assessed in various procedures. These numbers were intended to indicate numbers of procedures performed below which no trainee could reasonably expect to be competent, and most trainees require more than these minimal numbers. Unfortunately, the numbers have been widely used as goals to indicate competence. Research in objective evaluation of procedural skills makes revision of the guidelines at this time highly appropriate. Although developed with particular reference to gastroenterology fellowship programs, the following statement has broader applicability in other settings in which endoscopic training occurs.

Clinical and manometric effects of nitroglycerin in diffuse esophageal spasm.

THE major function of the esophagus is to transport material from the pharynx to the stomach. In diffuse esophageal spasm, a neuromuscular abnormality exists that can lead to painful swallowing, im...

Barrett's Esophagus: Clinical, Endoscopic, Histologic, Manometric, and Electrical Potential Difference Characteristics

The clinical, endoscopic, histologic, manometric, and esophageal potential difference characteristics of 20 patients with columnar epithelia lining the lower esophagus (Barretts esophagus) are presented. Endoscopically, two distinct types were identified: a circumferential-type and an island-type Barretts esophagus. Patients with these types exhibited similarities in mean age, duration of symptoms, mean lower esophageal sphincter pressure, and frequency of gross esophagitis. Only patients with the circumferential lesion, however, had esophageal strictures or esophageal ulcers. Manometric testing revealed a range of lower esophageal sphincter pressures from 3 to 33 mmHg and qualitative motor abnormalities (i.e., aperistalsis, repetitive waves, tertiary waves) in 3 patients. Histologically, the frequency of epithelial types was junctional greater than specialized columnar greater than atrophic fundic epithelium. More importantly, dysplasia was identified in 2 patients with the circumferential lesion and in 1 patient with the island lesion. Potential difference measurements demonstrated that a high potential difference (greater than -25 mV) was highly specific (92%), but only moderately sensitive (70%) for detecting Barretts esophagus. Based on these findings, we conclude (a) that there are at least two endoscopically distinct types of Barretts esophagus involving the lower esophagus--a circumferential type and an island type, (b) that both types are associated with chronic gastroesophageal reflux, with the island type being accompanied by less severe epithelial injury than the circumferential type, and (c) that the identification of dysplasia in the two types suggests that both are unstable lesions requiring continued surveillance with endoscopy and biopsy.

Failure of clinical criteria to distinguish between primary achalasia and achalasia secondary to tumor

Three clinical criteria have been reported to distinguish patients with primary achalasia from patients with achalasia secondary to tumor invasion of the gastroesophageal junction. These criteria (age greater than 50 years, duration of symptoms less than one year, and weight loss greater than 15 pounds) are important because of their potential use for deciding between pneumatic dilation and exploratory surgery. In the present investigation we assessed the frequency of these criteria alone and in combination in 79 patients with primary and in two patients with secondary achalasia seen at our institution over a 91/2-year period. Our results indicate that while these criteria are highly sensitive and moderately specific, their predictive value for distinguishing secondary achalasia from primary achalasia is exceedingly low. For this reason, early exploratory surgery is not indicated in patients with newly diagnosed achalasia who meet these criteria unless there is prior radiologic or endoscopic evidence for tumor.

The quality of care in Barrett's esophagus: endoscopist and pathologist practices.

BACKGROUND:The diagnosis of Barretts esophagus (BE) has important psychological and economic implications. Although accepted standards for endoscopic biopsy methods and pathological interpretation for BE exist, adherence to these standards as a measure of the quality of care in BE has not been evaluated. Our aim was to assess the quality of care in BE by evaluating the process of care and adherence to accepted standards of practice.METHODS:Explicit process-of-care criteria were developed using a systematic literature review and expert opinion in four domains of care: the quality of biopsy methods, the adequacy in identifying endoscopic landmarks, endoscopist–pathologist communication, and pathological interpretation and reporting. We reviewed all endoscopy and pathology reports of BE patients at two institutions from 1994–1997. An academic medical center (N = 237) with staff endoscopists and an academically affiliated community hospital (N = 100) with private-practice endoscopists were analyzed.RESULTS:Physicians showed the highest adherence to accepted standards of care in the “adequacy of identifying landmarks” and “endoscopist-pathologist communication” domains, with a ≥70% adherence rate in most criteria. Conversely, physicians demonstrated the poorest adherence with the “quality of biopsy methods” and “pathologist interpretation and reporting” domains, with adherence rates frequently <60%. Significantly, biopsies were taken in the presence of visible esophagitis 35% of the time. Performance on several of the quality indicators varied significantly by the practice setting.CONCLUSIONS:We have identified several opportunities for quality improvement efforts. In every domain, there is room for improvement, particularly in the quality of biopsy methods. As initiatives to screen the large population of gastroesophageal reflux disease patients for BE may be imminent, the time is now to define the critical process-of-care measures to minimize the risk of overdiagnosis and inadequate endoscopic surveillance.

Epidermolysis bullosa: gastrointestinal manifestations

Abstract Eight patients with epidermolysis bullosa dystrophica (recessive) and dysphagia were studied. Cases are described to illustrate that dysphagia may be reversible when caused by bullae forma...

Elevated vasoactive intestinal peptide concentrations in patients with irritable bowel syndrome.

The aim was to assess the roles of gut hormones and immune dysfunction in irritable bowel. In Study I, rectal mucosal samples examined blindly showed no histological evidence of inflammation in 16 irritable bowel patients compared to 17 healthy controls. The proinflammatory mediators interleukin-1β and prostaglandin E2 also failed to show evidence of inflammation. Vasoactive intestinal peptide was elevated in irritable bowel (P=0.01), but substance P, calcitonin gene-related peptide, and somatostatin levels were similar to control values. In Study II, 30 irritable bowel patients had elevated (P=0.002) plasma concentrations of vasoactive intestinal peptide compared to 30 controls, and peptide levels were unrelated to whether the patients predominant bowel habit was constipation, diarrhea, or both in alternation. In conclusion, no evidence of inflammation was detected in irritable bowel patients, but elevated vasoactive intestinal peptide concentrations were observed in both studies and might represent a potential diagnostic tool for irritable bowel syndrome.

Endoscopic Appearance of Cancer Metastatic to the Stomach

Genetic studies help to explain the pathogenesis, natural history, and nosology of the spectrum of gastroduodenal disorders encompassed by atrophic gastritis-pernicious anemia, gastric cancer, and peptic ulcer. All these disorders aggregate within families, and twin and disease-association studies have demonstrated that this aggregation has a genetic basis. Modern genetic studies are demonstrating that each of these disorders comprises several different diseases, and that many of the biochemical, physiologic, or immunologic abnormalities in such patients have a genetic basis. Thus, family members at risk can be identified. The optimum therapy and prevention of these diseases should ultimately depend on the specific genetic predisposition of the individual patient and family, and the recognition of individual susceptibilities to specific environmental influences.

Esophageal Potential Difference Measurements in Esophageal Disease

To determine if esophageal transmural electrical potential difference measurements are of use for evaluating esophageal disease, we recorded potential difference in 129 patients with one or more of the following: heartburn, dysphagia, and chest pain. All potential difference studies were performed at the time of esophageal manometry using a Ringer-perfused catheter technique which yields accurate and reproducible results in healthy subjects. In 103 of the 129 patients, esophageal potential difference measurements could be correlated with findings at manometry, endoscopy, and biopsy. The remaining 26 patients had primary esophageal motor disease and were not biopsied. The results of this investigation showed: (a) that 94% of patients with gross endoscopic lesions have an abnormal esophageal potential difference, (b) that an abnormal esophageal potential difference (found in only 1 of 24 patients with normal mucosa) is highly specific for the presence of esophageal mucosal disease, (c) that the type of potential difference abnormality may suggest the nature of the mucosal abnormality, for example high potential difference with Barretts esophagus and low potential difference with esophagitis or invasive carcinoma, and (d) that while an abnormal esophageal potential difference is highly sensitive for detecting gross esophagitis (38 of 40 patients), it is less sensitive for diagnosing microscopic esophagitis (8 of 16 patients). Based on these findings we conclude that the measurement of esophageal potential difference at the time of manometry can provide additional valuable information about the state of the esophageal mucosa.

Diagnosis of eosinophilic esophagitis after fundoplication for ‘refractory reflux’: implications for preoperative evaluation

A small percentage of patients who carry the diagnosis of refractory gastroesophageal reflux disease (GERD) actually have eosinophilic esophagitis (EoE). The purpose of this study was to describe a series of patients who underwent fundoplication for presumed refractory GERD, but subsequently were found to have EoE. We performed a retrospective analysis of our EoE database. Patients diagnosed with EoE after Nissen were identified. Cases were defined according to recent consensus guidelines. Five patients underwent anti-reflux surgery for refractory GERD, but were subsequently diagnosed with EoE. None had esophageal biopsies prior to surgery, and in all subjects, symptoms persisted afterward, with no evidence of wrap failure. The diagnosis of EoE was typically delayed (range: 3-14 years), and when made, there were high levels of esophageal eosinophilia (range: 30-170 eos/hpf). A proportion of patients undergoing fundoplication for incomplete resolution of GERD symptoms will be undiagnosed cases of EoE. Given the rising prevalence of EoE, we recommend obtaining proximal and distal esophageal biopsies in such patients prior to performing anti-reflux surgery.