Haim Pinkas

Esophagitis Associated with the Use of Alendronate

BACKGROUNDnAlendronate, an aminobisphosphonate and a selective inhibitor of osteoclast-mediated bone resorption, is used to treat osteoporosis in postmenopausal women and Pagets disease of bone. Aminobiphosphonates can irritate the upper gastrointestinal mucosa.nnnMETHODSnWe describe three patients who had severe esophagitis shortly after starting to take alendronate and also analyze adverse esophageal effects reported to Merck, the manufacturer, through postmarketing surveillance.nnnRESULTSnAs of March 5, 1996, alendronate had been prescribed for an estimated 475,000 patients worldwide, and 1213 reports of adverse effects had been received. A total of 199 patients had adverse effects related to the esophagus; in 51 of these patients (26 percent), including the 3 we describe in case reports, adverse effects were categorized as serious or severe. Thirty-two patients (16 percent) were hospitalized, and two were temporarily disabled. Endoscopic findings generally indicated chemical esophagitis, with erosions or ulcerations and exudative inflammation accompanied by thickening of the esophageal wall. Bleeding was rare, and stomach or duodenal involvement unusual. In patients for whom adequate information was available, esophagitis seemed to be associated with swallowing alendronate with little or no water, lying down during or after ingestion of the tablet, lying down during or after ingestion of the tablet, continuing to take alendronate after the onset of symptoms, and having preexisting esophageal disorders.nnnCONCLUSIONSnAlendronate can cause chemical esophagitis, including severe ulcerations, in some patients. Recommendations to reduce the risk of esophagitis include swallowing alendronate with 180 to 240 ml (6 to 8 oz) of water on arising in the morning, remaining upright for at least 30 minutes after swallowing the tablet and until the first food of the day has been ingested, and discontinuing the drug promptly if esophageal symptoms develop.

The importance of routine liver biopsy in diagnosing Nonalcoholic Steatohepatitis in bariatric patients

Background: Nonalcoholic Steatohepatitis (NASH) commonly occurs in obese patients and predisposes to cirrhosis. Prevalence of NASH in bariatric patients is unknown. Our aim was to determine the role of routine liver biopsy in managing bariatric patients. Methods: Prospective data on patients undergoing Roux-en-Y gastric bypass (RYGBP) was analyzed. One pathologist graded all liver biopsies as mild, moderate or severe steatohepatitis. NASH was defined as steatohepatitis without alcoholic or viral hepatitis. Consecutive liver biopsies were compared to those liver biopsies selected because of grossly fatty livers. Results: 242 patients underwent open and laparoscopic RYGBP from 1998-2001. Routine liver biopsies (68 consecutive patients) and selective liver biopsies (additional 86/174, 49%) were obtained. Findings of cirrhosis on frozen section changed the operation from a distal to a proximal RYGBP. The two groups were similar in age, gender, and BMI. The group with the routine liver biopsies showed a statistically significant larger preponderance of NASH (37% vs 32%). Both groups had a similar prevalence of cirrhosis. Neither BMI nor liver enzymes predicted the presence or severity of NASH. Conclusions: Routine liver biopsy documented significant liver abnormalities in a larger group of patients compared with selective liver biopsies, thereby suggesting that liver appearance is not predictive of NASH. Liver biopsy remains the gold-standard for diagnosing NASH. We recommend routine liver biopsy during bariatric operations to determine the prevalence and natural history of NASH, which will have important implications in directing future therapeutics for obese patients with NASH and for patients undergoing bariatric procedures.

Endoscopic therapy for esophageal carcinoma with Nd:YAG laser: prospective evaluation of efficacy, complications, and survival

Eleven consecutive patients who underwent endoscopic Nd: YAG laser therapy for palliation of esophageal carcinoma were prospectively evaluated between July 1, 1982, and December 31, 1982. All patients with tumor recurrence after radiotherapy or surgery (eight patients) or whose medical condition precluded surgery or full-course radiotherapy (three patients) underwent treatment. Mean tumor length was 8.1 cm and most had almost complete luminal occlusion. Survival was compared with patients with esophageal cancer treated at our institution during the 3 years prior to initiation of laser therapy (1978-1981). Treatment was completed in a mean of 3.3 sessions (range, 2 to 6). Dysphagia improved in all and performance status improved in eight patients, some markedly. Five patients with tumor re-occlusion were retreated at a mean of 10 weeks after initial therapy. No concurrent dilations were employed. Compared with our institutions historical controls, laser-treated patients survival was significantly increased, whether measured from time of onset of radiotherapy (36 vs. 17 weeks, p = 0.02) or from time of recurrent symptoms after radiotherapy (25 vs. 8 weeks, p less than 0.05).

Safety of conventional and wireless capsule endoscopy in patients supported with nonpulsatile axial flow Heart-Mate II left ventricular assist device

BACKGROUNDnLeft ventricular assist devices (LVADs) are increasingly being used as a bridge for cardiac transplantation in patients with decompensated cardiac function. A known complication of these devices is severe and sometimes life-threatening GI bleeding, usually related to the presence of angioectasias. Endoscopy has been generally accepted as safe in patients with cardiac disease and implanted cardiac devices, when it is performed with appropriate monitoring. However, the literature is sparse regarding the safety of endoscopy in patients with LVADs.nnnOBJECTIVEnGiven the potential risks for GI bleeding in this subgroup of patients, our aim was to shed light on the potential safety of endoscopy in these patients.nnnDESIGNnWe present our experience with endoscopic intervention for varied sources of GI bleeding in a group of patients with the HeartMate II implantable LVAD.nnnSETTINGnA tertiary care university-based hospital setting, Tampa General Hospital at the University of South Florida, Tampa, Florida.nnnPATIENTSnPatients with severe cardiomyopathy requiring cardiac support with the HeartMate II implantable LVAD.nnnINTERVENTIONSnPatients received upper and lower GI endoscopy as dictated by their clinical presentations. One patient received capsule endoscopy as well.nnnCONCLUSIONSnWe observed that endoscopy, including capsule endoscopy, may be safely performed in these patients with appropriate monitoring.

Acute cholecystitis after palliative stenting for malignant obstruction of the biliary tree

Endoscopic and percutaneous stenting of the biliary tree is an effective therapeutic option in the palliation of the patient with obstructive jaundice. Relief of pruritis and progressive improvement in jaundice is usually evident within days. About 80 % of patients leave the hospital with functioning prostheses, and most of these patients remain free of obstructive jaundice for months.! Early mortality may be as high as 16 %, with most deaths the result of cholangitis with sepsis or progression of the terminal disease.! Complications occurring after biliary prosthesis insertion include cholangitis, bile duct perforation, bleeding, pancreatitis, and stent obstruction.2 An infrequent occurrence after stent placement is acute cholecystitis.2, 3 We report six cases of acute cholecystitis after stent placement for palliation of malignant extrahepatic biliary obstruction.

Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy

Endoscopic retrograde cholangiopancreatography (ERCP) is a useful adjunct to laparoscopic cholecystectomy. Preoperative ERCP is indicated if there is a high degree of suspicion for common duct stones, when severe gallstone-induced pancreatitis is present, or when there is uncertainty regarding the diagnosis. The best indicators of common duct stones preoperatively are an elevated bilirubin, a dilated common bile duct (CBD) on sonography, or stones visualized in the CBD on sonography. Mild gallstone pancreatitis and transient mild elevations in liver enzymes are not predictive of CBD stones and are not indications for ERCP. Postoperative ERCP is highly effective in clearing CBD stones. It has the advantage of being more readily available as compared to laparoscopic CBD exploration, and preserves all the advantages of the laparoscopic approach. Post-operative ERCP is indicated for retained CBD stones, evaluation and therapy of biliary injuries, and persistent biliary symptoms or abnormal liver enzymes and bilirubin. ERCP is the procedure of choice for the evaluation of laparoscopic biliary injuries. Major biliary injuries will generally require surgical therapy. Bile duct strictures are sometimes amenable to endoscopic therapy with dilation and stents. Biliary leaks are readily treatable with endoscopic therapy. Small cystic duct stump leaks and leaks from a duct of Lushka close within a few days with nasobiliary drainage. Larger leaks may require more prolonged drainage with stents and early supplemental percutaneous drainage of an accompanying biloma. Bilious ascites should be treated with nasobiliary drainage using low suction to be prevent contamination of the peritoneal cavity with intestinal flora, and simultaneous percutaneous ascites drainage. Biliary leaks, unless associated with major bile duct injuries, rarely require surgical therapy.

Prolonged evaluation of epinephrine and normal saline solution injections in an acute ulcer model with a single bleeding artery

BACKGROUNDnAnimal studies of epinephrine or normal saline solution injection for bleeding ulcers do not consistently demonstrate local tamponade effect.nnnMETHODSnWe studied the change of bleeding rates of 28 acute gastric ulcers with a single bleeding artery in 10 dogs. Four injections of 1 mL epinephrine 1:10000 at 1 mm from the spurting artery (n = 7) were compared to four injections of normal saline solution 1 to 5 mL (n = 12) and to four dry needle sticks (n = 9). Bleeding rates were measured at initial arterial incision and at minutes 1, 5, 10, 15, 20, 25, and 30 after treatment.nnnRESULTnReductions in early blood loss to 24.3% +/- .05 of baseline occurred with saline solution, to 17.7% +/- .03 with epinephrine, and to 66.0% +/- 1.8 in controls (p < .05 for epinephrine and saline solution vs control). A tendency for saline solution injected ulcers to resume bleeding was identified, with late blood loss increasing to 26.9% +/- .05 of baseline, (saline solution vs control) compared to 7.7% +/- .02 in epinephrine injected ulcers (p < .05 vs control).nnnCONCLUSIONSnThe early acute hemostatic effect of injection therapy depends on local tamponade. The prolonged hemostatic effect is a combination of tamponade and vasoconstriction, with advantage of epinephrine over saline solution.

Successful endoscopic transpapillary drainage of an infected pancreatic pseudocyst

A 58-year-old man was admitted for evaluation of a 3-day history of nausea, vomiting, right upper quadrant pain, and tenderness without fever. He had a history of gallstones but denied the use of alcohol. Admission laboratory evaluation revealed a mild leukocytosis without a left shift. Serum GG T was elevated to five times normal value with otherwise norxad mal liver enzyme levels. Serum amylase and lipase were elxad evated three and 10 times normal values, respectively. Serum calcium and triglyceride levels were normal. With the suspicion of gallstone-induced pancreatitis, the patient was taken to the operating room. Operative findings included cholelithiasis, chronic cholecystitis with a normal operative cholangiogram, and hemorrhagic pancreatitis. A cholecystectomy was performed. Three weeks postoperaxad tively, the patient had persistent fever, leukocytosis, and abdominal pain despite a I-week course of broad-spectrum antibiotics. A CT -guided percutaneous drain was placed in the lesser sac for drainage of peri pancreatic fluid, with subxad sequent clinical improvement. Six weeks after percutaneous drain placement, it was accidentally displaced with re-accuxad mulation of peripancreatic fluid accompanied by symptoms of abdominal pain, nausea, and vomiting. An operative cystogastrostomy was then performed with operative findings of a thick-walled infected pseudocyst, cultures of which grew Staphylococcus aureus. Three weeks postoperatively, the patient again became febrile with inxad creased abdominal pain. Abdominal CT scan showed central cavitary necrosis of the pancreas (Fig. 1). Additionally, mulxad tiple intra-abdominal fluid collections were present. A CTxad guided percutaneous catheter was placed in the right para

Delayed presentation of complete pancreatic ductal transection in children: management of two cases without resection

Pancreatic ductal injuries in children are rare, and ductal transections presenting in a delayed or subacute fashion are seldom reported. We describe two cases of traumatic pancreatic ductal transection secondary to physical abuse, both of which presented late to medical care. Both were managed successfully without pancreatic resection. Judicious application of non-resectional management can yield favorable outcomes in this subset of pediatric patients.

Multicenter evaluation of the clinical utility of laparoscopy-assisted ERCP in patients with Roux-en-Y gastric bypass

BACKGROUND AND AIMSnThe obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP.nnnMETHODSnThis is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated.nnnRESULTSnA total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred.nnnCONCLUSIONSnOur large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.