George W. Meyer

Hepatobiliary Involvement in von Recklinghausen's Disease

Excerpt Von Recklinghausens disease is a syndrome characterized by multiple cutaneous neurofibromas, cafe-aulait spots, and a broad spectrum of clinical, pathologic, and radiologic findings. Von R...

Efficacy of atropine as an endoscopic premedication

To determine the efficacy of atropine as an endoscopic premedication, we prospectively evaluated in double-blind fashion 196 elective endoscopies performed on 189 consecutive consenting patients. Group 1 (95 endoscopies) received meperidine, 1.5 mg/kg, intramuscularly 30 min prior to endoscopy. Group 2 (101 endoscopies) additionally received atropine, 0.6 mg, in the same injection. Endoscopy was performed by one of two investigators using a 13-mm fiberoptic instrument. Endoscopists and patients filled out postendoscopy questionnaires. Both endoscopists (p less than 0.01) and patients (p less than 0.05) noted less oral secretions after atropine. Endoscopists noted less gastric motility after atropine (p less than 0.05) and guessed correctly whether or not atropine had been given in two thirds of cases. They noted no overall difference, however, in the ease of the endoscopy (p greater than 0.05). Moreover, there were no differences in the patients assessments of the acceptability of the procedure between the two groups (p greater than 0.05). We concluded that although atropine does not improve patients tolerance for the examination or the endoscopists ability to do an adequate examination, it does objectively decrease the amount of gastric motility and oral secretions. This latter effect could potentially decrease the hazard of aspiration, but such a benefit could not be demonstrated in our series.

Isolated polyarteritis nodosa affecting the cecum

SummaryWe report the case of a 52-year-old white male who developed low back pain and 35-pound weight loss and whose barium enema revealed a constricting lesion of the cecum. After resection, polyarteritis was found to be the cause of the lesion. There was no other histological evidence for arteritis in this patient.We report the case of a 52-year-old white male who developed low back pain and 35-pound weight loss and whose barium enema revealed a constricting lesion of the cecum. After resection, polyarteritis was found to be the cause of the lesion. There was no other histological evidence for arteritis in this patient.

Current concepts of esophageal function

Current state of the art methods for esophageal manometry may be performed with either a nonperfused probe with intraluminal transducers or a perfused catheter system. The perfusate should be driven by a low compliance pump through catheters 0.8 mm. in diameter. The upper esophageal sphincter pressure profile is asymmetrical, with higher pressures in the anterior and posterior directions than laterally. The lower esophageal sphincter pressures are higher in the left and left posterior directions. There is symmetry of peristaltic pressures in the body of the esophagus. The discussion of the physiology of swallowing includes the on response and the off and duration response. The lower esophageal sphincter is normally in a state of constant contraction and is relaxed following stimulation of the vagus nerve. The mechanisms of the control of the lower esophageal sphincter remain to be fully demonstrated.

Evaluation and management of diseases of the esophagus

Current methods to evaluate patients with esophageal disease include barium swallow with fluoroscopy, which is useful in demonstrating structural defects. Disordered motility is better evaluated with a cine-esophagram. Recent application of radioisotopes has been useful in evaluation of esophageal reflux and the post-treatment of achalasia. Esophageal motility studies may evaluate lower esophageal sphincter and upper esophageal sphincter pressures and the response of the body of the esophagus to series of swallows. Since there is no gold standard for the evaluation of reflux esophagitis, some of the tests designed to evaluate reflux and the patients reaction to acid in the esophagus include the acid infusion test, the standard acid reflux test, the acid clearance test, and 24-hour pH monitoring. Endoscopy with either the flexible or the rigid instrument is important for the diagnosis of obstruction or esophagitis and allows direct visualization of the esophagus. The treatment of reflux esophagitis is discussed. The differential diagnosis of dysphagia may include achalasia, diffuse esophageal spasm, and mechanical obstruction of the esophagus due to rings, webs, strictures, and benign or malignant tumors. The evaluation of dysphagia should include radiologic as well as endoscopic evaluation. Treatment of obstruction varies according to the nature of the lesion. The Mallory-Weiss syndrome or bleeding from the mucosal tears of the gastroesophageal junction and Boerhaaves syndrome, spontaneous esophageal perforation, are two disorders associated with vomiting. The Mallory-Weiss syndrome usually resolves without specific therapy, but a high index of suspicion is required for patients with chest pain after vomiting, as spontaneous perforation necessitates immediate surgery. Most diverticula need no treatment, but the Zenker diverticulum, if symptomatic, should probably be surgically repaired.

Prophylaxis of infective endocarditis during colonoscopy: report of a survey

Ninety-eight directors of infectious disease training programs responded to a questionnaire about bacterial endocarditis prophylaxis for susceptible patients during colonoscopy. Although 54% recommended a penicillin and an aminoglycoside, antibiotics commonly used to protect against the enterococcus, there are no published data to support the use of prophylaxis. Most directors of gastrointestinal training programs do not routinely use antibiotic prophylaxis during colonoscopy. If antibiotics are chosen, they should include a penicillin and an aminoglycoside or vancomycin (alone or with aminoglycoside) at the dosage schedule suggested by the American Heart Association Committee.

In support of the clinical usefulness of lower esophageal sphincter pressure determination

The lower esophageal sphincter (LES) was first identified manometrically by Fyke et al in 1956 (I). Since that time, there has been much controversy about the value of its measurement. In those early days of esophageal manometric studies, techniques using water-fiUed, noninfused catheters did not allow separation of subjects with normal LES pressures from patients with major reflux symptoms, presumably with low pressure incompetent sphincters. With the development of the infused catheter technique by Pope in the mid-1960s, clear separation of sphincter pressures was found between normals (if( = 24.8 mmHg) and patients who had reflux (.Y = I 1.6 mm Hg; P < 0.005). LES pressures for the two groups measured by noninfused catheters were not different (2). Winans and Harris confirmed that an infused system gave higher LES pressures and again found clear separation between normal subjects and patients with reflux (3). It is important to recall that these initial studies were, in fact, identifying two ends of a spectrum; patients with severe daily heartburn and subjects who were totally without symptoms. This seems appropriate, for in the development of any new potentially discriminatory test one must first ask whether it can identify the extremes. Predictably, as clinical experience with infused catheter techniques for measuring LES pressure was extended, it became clear the LES pressure measurement alone could not always identify patients with reflux when symptoms were equivocal. This observation should in no way detract from the excellent studies resulting in the initial description of the technique of

Intestinal bypass and zinc.

Excerpt To the editor: The recent observations of decreased zinc and copper levels in patients after intestinal bypass procedures in the absence of skin lesions seems, at first glance, to be an obs...

Effect of atropine and upper gastrointestinal endoscopy on serum gastrin

To determine if atropine alone, gastric distension alone, or atropine plus gastric distension affected serum gastrin levels, we obtained serum gastrins on 45 consecutive patients who were randomized into two groups. Group 1 (27 patients) was premedicated with meperidine alone, 1.5 mg/kg I.M. Group 2 received atropine 0.6 mg I.M. in addition to meperidine. Blood samples were drawn: 1) before premedication, 2) 30 minutes after premedication, and 3) immediately after endoscopy. We found: 1) no statistical difference between mean basal gastrin levels for groups 1 and 2, 2) no change in basal serum gastrin levels after premedications in either group, and 3) that endoscopy caused no significant increase in mean serum gastrin levels. We conclude that endoscopy does not lead to a significant elevation of basal serum gastrin in patients premedicated with meperidine or meperidine and atropine.