Harvey S. Young

An annotated algorithmic approach to acute lower gastrointestinal bleeding.

Summary Colonoscopy is the procedure of choice for theevaluation of acute LGIB. Upper endoscopy shouldbe performed when an upper source is suspected orwhen evaluation of the colon is negative. Ifcolonoscopy and upper endoscopy fail to reveal ableeding source, evaluation of the small bowelshould be considered. Angiography and/or ableeding scan may be appropriate in the setting ofmassive bleeding, persistent bleeding, or a non-diagnostic colonoscopy. Pre-operative localizationof bleeding should be attempted in all patients priorto surgical intervention except in rare circumstanceswhen massive hemorrhage necessitates emergentsub-total colectomy. References 1. Waye JD. Diagnostic endoscopy in lower intestinalbleeding. In: Sugawa C, Schuman BM, Lucas CE,editors. Gastrointestinal bleeding. New York: IgakuShoin Medical Publishers; 1992. p. 230-41. 2. Zuccaro G. Approach to the patient with acute lower GIbleeding. ASGE Clinical Update 1999;7. 3. Zuckerman GR, Prakash C. Acute lower intestinalbleeding Part I: Clinical presentation and diagnosis.Gastrointest Endosc 1998; 48:606-16. 4. ASGE. The role of endoscopy in the patient with lowergastrointestinal bleeding: guidelines for clinicalapplication. Gastrointest Endosc 1998;48:685-8. 5. Ebert RV, Stead EA, Gibson JG. Response of normalsubjects to acute blood loss. Arch Int Med1941;68:578. 6. Committee on Trauma, American College of Surgeons.Advanced trauma life support. 5th ed. Chicago:American College of Surgeons; 1993. p. 84. 7. Jensen DM, Machicado GA. Diagnosis and treatmentof severe hematochezia. The role of urgentcolonoscopy after purge. Gastroenterology1988;95:1569-74. 8. Luk GD, Bynum TE, Hendrix TR. Gastric aspiration inlocalization of gastrointestinal hemorrhage. JAMA1979;241:576-8. 9. Cuellar RE, Gavaler JS, Alexander JA, et al.Gastrointestinal tract hemorrhage. The value of anasogastric aspirate. Arch Intern Med1990;150:1381-4. 10. Zuckerman GR, Prakash C. Acute lower intestinalbleeding Part II: Etiology, therapy, and outcomes.Gastrointest Endosc 1998;49:228-38.11. Rossini FP, Ferrari A, Spandre M, et al. Emergencycolonoscopy. World J Surg 1989;13:190-2. 12. Caos A, Benner KG, Manier J, et al. Colonoscopyafter Golytely preparation in acute rectal bleeding. JClin Gastroenterol 1986;8:46-9. 13. Forde KA. Colonoscopy in acute rectal bleeding.Gastrointest Endosc 1981;27:219-20. Citation14. Zuccarro G. Management of the adult patient withacute lower gastrointestinal bleeding. Am JGastroenterol 1998;93:1202-8. Citation

Radiotherapy, concomitant protracted-venous-infusion 5-fluorouracil, and surgery for ultrasound-staged T3 to T4 rectal cancer

BACKGROUND: A prospective study was undertaken to evaluate the response and toxicity of neoadjuvant chemoradiotherapy for ultrasound-staged T3 or T4 rectal cancer. PATIENTS AND METHODS: Since 1995, 30 patients (18 males; median age, 56 (range, 25–83) years) have received preoperative chemoradiotherapy for ultrasound-staged T3 or T4 rectal cancer. All patients underwent an endorectal ultrasound, CT scan, and review in our multidisciplinary Gastrointestinal Tumor Board before treatment. All patients had pathology-demonstrated invasive adenocarcinoma of the rectum. Eleven patients were Stage T3N0, 14 were T3N1, and five were T4N1. Patients received radiotherapy to the primary tumor and draining lymph nodes (45 Gy) followed by a tumor boost (50.4–54 Gy). Protracted-venous-infusion 5-fluorouracil (225 mg/m2 per day, seven days per week) was administered throughout treatment. Surgical resection was performed six to ten weeks after completing chemoradiotherapy. Using endorectal ultrasound measurements, the primary tumor was a median of 4 (range, 0–12) cm from the anal verge, encompassed 50 (range, 20–90) percent of the rectal circumference, and was 6 (range, 3–12) cm in diameter. RESULTS: No Grade 4 toxicity was observed during chemoradiotherapy. Three patients experienced Grade 3 toxicity (diarrhea), and four patients required a treatment interruption of greater than three days. All patients completed at least 90 percent of the prescribed radiotherapy dose. All patients underwent surgical resection. Ninety-four percent had clear surgical margins. All pathologic specimens had significant evidence of necrosis, hyalinization, and fibrosis. Thirty-three percent of the specimens had a complete pathologic response (defined as no evidence of viable tumor cells). Of the 19 patients with ultrasound-staged N1 disease, only five had pathologic evidence of nodal involvement after chemoradiotherapy. Of the 25 patients with ultrasound-staged T3 disease, pathologic staging revealed eight with T0, two with T1, five with T2, and ten with T3 disease. Of the five patients with ultrasound-staged T4 disease, pathologic staging revealed two with T0, one with T2, and two with T3 disease. No patient developed progressive disease while on treatment. Two patients have experienced local failure at 6 and 20 months, and one patient failed in the liver at seven months. Twenty-seven patients remain free of disease with a median follow-up of 20 (range, 3–53) months. CONCLUSION: Our experience suggests that preoperative chemoradiotherapy is well tolerated, down-stages tumors, and sterilizes regional lymph nodes.

An annotated algorithmic approach to upper gastrointestinal bleeding.

Algorithms for appropriate utilization of endoscopy are based on a critical review of the currently available data and expert consensus. Controlled clinical studies may in some cases be needed to clarify aspects of this statement, and revision may be necessary as new data appear. These algorithms are intended to serve as a guide for management of common clinical scenarios potentially involving endoscopy. They are not meant to replace clinical judgment/expertise. In some cases, a course of action at variance with these recommendations may be indicated. Upper gastrointestinal (UGI) bleeding is a common medical presentation for patients seen by gas-troenterologists and is associated with significant morbidity, mortality and the use of healthcare resources. It is estimated that greater than 350,000 hospital admissions for UGI bleeding occur annually with an overall mortality rate of approximately 10%. 1 Endoscopy should be considered a primary and piv-otal early intervention in establishing the source of bleeding. Early endoscopy allows clinicians an opportunity for therapeutic interventions and estimation of an individuals risk for recurrent bleeding. These benefits impact greatly on practical patient management since therapeutic interventions have been shown to reduce adverse outcomes associated with UGI bleeding and allow clinicians the opportunity to choose the appropriate level of care and resource utilization commensurate with their likelihood of rebleeding. With selective use of ambulatory services and health care resources, early endoscopy with therapeutic interventions is associated with lower cost of care and with equal or improved medical outcomes. 2,3 INITIAL EVALUATION, RESUSCITATION AND STABILIZATION The evaluation of patients with suspected UGI bleeding requires initial clinical assessment including a history and physical exam that focuses on the possible etiology of bleeding and the severity of the bleeding (Figure 1 A). This should include an evaluation for the common causes of bleeding such as peptic ulcer disease, Mallory-Weiss tears, esophagitis and esophageal/gastric varices, among others. 4 It is important to recognize that the morbidity and mortality associated with varices remains high and requires timely and specific therapeutic interventions (sclerosis, banding, TIPS, surgery) to reduce the associated adverse outcomes. An algorithm for UGI bleeding in patients with known or suspected cirrho-sis with varices has been the subject of an additional ASGE review. 5 Complicating factors such as age, comorbid medical conditions, the use of anticoagulants and clotting disorders (congenital or acquired) are important historical factors to identify. Patients should also be asked about the use of prescription and over-the-counter NSAIDs …

The utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with presumed sphincter of Oddi dysfunction.

Objectives:We sought to study the utility of liver function test abnormalities concomitant with biliary symptoms in predicting a favorable response to endoscopic sphincterotomy in patients with Geenen class II sphincter of Oddi dysfunction.Methods:We reviewed the clinical course and liver function test results of 24 Geenen-Hogan class II postcholecystectomy patients with biliary colic secondary to sphincter of Oddi dysfunction who did not undergo sphincter of Oddi manometry before treatment with endoscopic sphincterotomy.Results:Twenty of the 24 patients had an average of 1.4 episodes of abnormal liver function tests associated with biliary colic; eight patients had dilated common bile duct on cholangiogram. Eighteen of the 20 patients with abnormal liver function tests (90%) were pain-free after sphincterotomy; in contrast, only one of four patients (25%) without liver function test changes responded to sphincterotomy. Fisher exact analysis showed that abnormal liver function tests was a significant predictor for favorable response to sphincterotomy with a two-tail p value of 0.018. Of the eight patients with bile duct dilatation, six (75%) responded favorably to sphincterotomy, whereas 13 of 16 patients (81%) without dilatation also responded to sphincterotomy. Analysis of common bile duct dilatation as a predictive factor showed no significance (p= 1.00).Conclusions:We conclude that the occurrence of abnormal liver function tests during biliary colic may be used to select patients for endoscopic sphincterotomy. Sphincter of Oddi manometry may not be needed in these cases.

An annotated algorithm for the evaluation of choledocholithiasis

VOLUME 53, NO. 7, 2001 Individuals with choledocholithiasis (common bile duct stones or CDL) can present with biliary colic, nonspecific abdominal pain, obstructive jaundice, cholangitis, or acute biliary pancreatitis. Individuals may also harbor asymptomatic stones that are diagnosed serendipitously. The diagnostic studies available are imperfect, and therapies range from expectant management to endoscopic stone extraction or surgery, depending on the clinical scenario. Choledocholithiasis cannot reliably be diagnosed on the basis of the patient’s history and physical examination alone. Patients with CDL may complain of nausea, emesis, bloating or right upper quadrant/ epigastric discomfort, but these symptoms are not necessarily predictive of CDL. Elevations of serum levels of alkaline phosphatase (AP), gamma glutamyl transpeptidase (GGT), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) with associated symptoms suggest CDL, especially in patients with known gallbladder stones. Almost all

Clinical presentation of mucin-secreting tumors of the pancreas

BACKGROUND Pancreatitis and jaundice secondary to ductal obstruction are common in intraductal papillary mucinous tumors (IPMT) of the pancreas. However, the incidence and severity of the complications of obstruction are not well documented. The aim of the study was to investigate the clinical presentation and outcome of 10 patients with IPMT. METHODS All cases of IPMT diagnosed between 1994 and 1999 were reviewed. RESULTS Four of the 10 patients developed severe acute illness with systemic complications resulting from ductal obstruction. Three suffered acute cholangitis with sepsis, and 1 developed necrotizing pancreatitis and ARDS. There was 1 postoperative death in a patient with adenocarcinoma. All other patients are alive and well with a median follow-up of 26 months (survival 90%). CONCLUSIONS Pancreatic or common bile duct obstruction in IPMT may result in acute, life-threatening disease. Aggressive surgical therapy is warranted before development of complications of ductal obstruction or progression of tumor occurs.

Use of endoscopy in diarrheal illnesses.

Abstract Guidelines for the practice of endoscopy are developed by the American Society for Gastrointestinal Endoscopy using evidence-based methodologies. A literature search is performed to identify relevant studies on the topic. Each study is then reviewed for both methodology and results. Controlled clinical trials are emphasized, but information is also obtained from other study designs and clinical reports. In the absence of data, expert opinion is considered. When appropriate, the guidelines are submitted to other professional organizations for review and endorsement. As new information becomes available revision of these guidelines may be necessary. These guidelines are intended to apply equally to all who perform gastrointestinal endoscopic procedures, regardless of specialty or location of service. Practice guidelines are meant to addresses general issues of endoscopic practice. By their nature, they cannot encompass all clinical situations. Clinical situations may justify a course of action at variance to these recommendations.

Adenocarcinoma of the rectum with associated colorectal adenomatous polyps in tuberous sclerosis: A case report

The authors present the case of a 17-year-old girl with tuberous sclerosis (TS) who presented with symptoms of intussusception. Although endoscopically diagnosed with multiple colonic polyps, presumed to be hamartomas, and an invasive rectal adenocarcinoma, postoperative pathology findings confirmed the rectal cancer and showed multiple colonic adenomas. Multiple colonic adenomatous polyps in a young girl with tuberous sclerosis is extremely rare. Furthermore, we believe that this is the first report of an invasive adenocarcinoma of the large intestine occurring in a patient with TS.

Envelope amplitude analysis following narrow‐band filtering: A technique for ultrasonic tissue characterization

Ultrasonic waveforms backscattered from tissue simulating phantoms and from normal and cirrhotic human livers in vivo were digitized to a standard dynamic range prior to envelope detection and determination of envelope amplitude distributions. For 11 individual narrow-band Gaussian-shaped filters of -6 dB bandwidth 200 kHz, and of center frequencies from 2 to 4 MHz, envelope amplitude distributions were plotted and mean values of the values distributions computed. Analysis of data was performed for data from a phantom containing only relatively small graphite scatters (less than 170 mu), and a similar phantom to which glass spheres 0.5 mm in diameter had been added homogeneously. For lower center frequency narrow-band filters, significantly more high-amplitude occurrences were observed for data from the phantom to which glass spheres had been added. Higher center frequency narrow-band filters gave significantly more high-amplitude occurrences for the phantom containing only small scatters. Similar data analysis was performed for in vivo human liver data from ten normal subjects and five patients with known cirrhosis of the liver. For the cirrhotic and normal livers, data analysis using narrow-band filters of relatively low center frequency resulted in more high- amplitude occurrences for cirrhotic, compared to normal liver; the converse was true for narrow-band filtration at relatively high center frequencies. Determination of mean amplitude following narrow-band filtration with a filter centered at 3.4 MHz was found to be quite repeatable for the normal and cirrhotic liver data; analysis of variance showed the measurement was 94.1% a function of the subject examined, and 5.9% related to the data acquisition session.(ABSTRACT TRUNCATED AT 250 WORDS)