Jay J. Mamel

Incidence of pancreatitis in patients undergoing sphincter of Oddi manometry (SOM)

Objective:Sphincter of Oddi manometry (SOM) is a useful diagnostic procedure when evaluating patients with unexplained biliary pain or idiopathic recurrent pancreatitis. Acute pancreatitis is a recognized complication of SOM whose pathogenesis appears to be multifactoral. We conducted this study to determine the incidence of pancreatitis in patients after SOM and to identify any variables that may lead to an increased incidence of pancreatitis.Methods:A retrospective review of 100 consecutive patients who underwent SOM between 1992 and 1996 at two university-affiliated hospitals was done. SOM was performed using a triple lumen catheter with each lumen perfused at a rate of 0.25 cc/min using an Arndorfer pneumohydraulic capillary perfusion system. The following data were recorded: age, gender, clinical type of sphincter of Oddi dysfunction, length of procedure, doses of medications used, duct cannulated, sphincter of Oddi pressure, whether endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy was performed, and the number of patients developing pancreatitis. Statistical analysis was performed using a T test, χ2, and multiple regression analysis.Results:The overall incidence of pancreatitis was 17%. Six patients with type II SO dysfunction and 11 patients with type III SO dysfunction developed pancreatitis. The incidence of pancreatitis was significantly lower in those patients who only had SOM, compared with those patients who had SOM and ERCP (9.3%vs 26.1%, p < 0.026). There was no significant correlation between age, gender, duration of procedure, dose of midazolam used, sphincter of Oddi pressure, or type of SO dysfunction with the development of SOM-induced pancreatitis. Multiple regression analysis showed that sphincterotomy added no additional risk, beyond that associated with ERCP, for the development of pancreatitis.Conclusions:The results of this study indicate that the incidence of pancreatitis was highest when SOM was followed by ERCP. A potential method of decreasing the incidence of pancreatitis after SOM is performing ERCP with or without sphincterotomy at another session, separated from the SOM by at least 24 h. Before this can be definitely recommended, the results of this study must be validated by others or by a prospective study.

Esophageal Cast: A Manifestation of Graft-versus-Host Disease

Diffuse involvement of the gastrointestinal tract by graft-versus-host disease (GVHD) is a common complication of bone marrow transplantation. The esophageal involvement in this disease tends to be a vesiculobullous, ulcerative or desquamative process. To our knowledge, esophageal cast has not been described in the context of GVHD. However, it has been described as a result of trauma to the esophagus or in association with bullous disease of the skin. We present a case of esophageal cast in a patient with chronic GVHD following bone marrow transplant.

Resolution of symptomatic GERD and delayed gastric emptying after endoscopic ablation of antral diaphragm (web)

A prepyloric antral diaphragm is a rare anomaly of the gastric antrum that results from incomplete canalization of the foregut during the fifth and sixth weeks of embryonic development.1 Others believe that an antral diaphragm can be an acquired abnormality.2 About 150 cases have been reported since the initial description by Touroff et al.3 in 1940. Histologically, the antral diaphragm consists of normal gastric mucosa, submucosa, and muscularis mucosa.4 Symptoms depend on the size of the diaphragm’s aperture. If the aperture is less than 1 cm, obstructive symptoms are likely to be present. The usual treatment of these patients has been surgical resection of the diaphragm. Other treatments have included endoscopic resection with a snare,5 endoscopic transection with a papillotome,6 and endoscopic laser therapy.7 We report the case of a successful endoscopic ablation of an antral diaphragm.

Colon Cancer Metastatic to the Biliary Tree.

Metastasis of colon adenocarcinoma is commonly found in the lung, liver, or peritoneum. Common bile duct (CBD) tumors related to adenomas from familial adenomatous polyposis metastasizing from outside of the gastrointestinal tract have been reported. We report a case of biliary colic due to metastatic colon adenocarcinoma to the CBD. Obstructive jaundice with signs of acalculous cholecystitis on imaging in a patient with a history of colon cancer should raise suspicion for metastasis to CBD.

Chromoendoscopy Facilitates the Identification of Adenomatous Polyps Arising on the Ileocecal Valve

The ileocecal valve anatomy is variable. Sometimes the lips of the ileocecal valve may appear thickened by fat accumulation [1, 2]. Under these circumstances it can be difficult to differentiate between a thickened lip and a polyp arising on its mucosal surface. We present a 36-year-old white female who underwent colonoscopic examination to investigate lower gastrointestinal bleeding. The lips of the ileocecal valve were thickened and could easily be interpreted as fat accumulation (fig. 1a). It was difficult to define the surface characteristics of the thickened area of the ileocecal mucosa. However, after staining with 2% indigo carmine, the surface characteristics were obvious, showing normal mucosa of the superior lip, but the inferior lip showed evidence of prominent sulci highly suggestive of adenomatous polyposis (fig. 1b) [3]. The polyp was removed with polypectomy snare, and the histology confirmed a tubulovillous adenoma with low-grade dysplasia completely resected. The usefulness of chromoendoscopy has been evaluated and was found to provide morphological details of various types of mucosal lesions [3–5]. Chromoendoscopy can be very useful in differentiating betwen normal thickening of the ileocecal valve lips and adenomatous changes. This can be advantageous in this situation where the alternative was to biopsy the site to confirm the adenomatous change. But this would require a second colonoscopy to complete the removal of the adenoma, incurring further cost and inconvenience for the patient.

Use of Endoscopy in Peptic Ulcer Disease

The diagnosis and treatment of acute bleeding caused by peptic ulcer disease has been greatly facilitated by fiberoptic endoscopy. The basic differentiation between malignant and benign gastric ulcer requires endoscopic confirmation with biopsy. The management of bleeding from peptic ulceration can be enhanced by endoscopic examination as can the prediction of risk for recurrent bleeding or need for surgical intervention. Various therapeutic maneuvers can be performed endoscopically, including monopolar and multipolar cautery, laser and heater probe therapy, and injection of vasoconstrictors to control bleeding. Endoscopic balloon dilation for the management of gastric outlet obstruction is often effective.

A Rare Cause of Overt Gastrointestinal Bleeding

A 22-year-old man with a history of traumatic paraplegia presented with decubitus ulcers. (Left) Computerized tomography confirmed massive hepatomegaly. Magnetic resonance imaging revealed acute-on-chronic osteomyelitis involving the majority of the right hip. Liver needle biopsy findings were consistent with reactive AA (serum amyloid A)–type deposition (center), confirmed by liquid chromatography–tandem mass spectrometry, with extensive Congo red–positive amyloid deposits (right). The preferred therapy for reactive AA amyloidosis is control of the underlying inflammatory disease.

Reduction in the incidence of pancreatitis in patients undergoing sphincter of Oddi manometry: a successful quality improvement project.

Objective Acute pancreatitis is a recognized complication of sphincter of Oddi manometry (SOM). Its frequency of occurrence has been reported in the range of 4 to 31%. In an earlier retrospective study performed at this institution, the incidence of pancreatitis was 9.3% in patients who only had SOM compared with 26.1% in those patients who had SOM and endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy at the same session. On the basis of these data, a quality-improvement project was initiated at two university-affiliated hospitals. This involved performance of SOM without ERCP. If ERCP was required, it was performed at a different session. The purpose of this project was to decrease the incidence of pancreatitis associated with SOM. Methods This study involved prospective patient identification and retrospective chart review of patients who underwent SOM without ERCP between May 1998 and December 2000. SOM was performed using a triple-lumen catheter with water perfusion at a rate of 0.25 ml/min using an Arndorfer pneumohydraulic capillary perfusion system. The data recorded included pancreatitis after SOM, pancreatitis after ERCP and sphincterotomy, average days in the hospital after pancreatitis, and time between SOM and ERCP. Results Forty-one patients were studied. Three (7.32%) patients had pancreatitis after SOM. Five patients subsequently underwent ERCP and sphincterotomy and one (20%) patient had pancreatitis. The overall frequency of pancreatitis after SOM and any subsequent ERCP or sphincterotomy was 4 (9.78%) of 41 (95% confidence interval, 3.9–22.5%). The odds ratio for pancreatitis with ERCP and SOM at the same time compared with the SOM-only strategy was 3.26 (P = 0.05). The average stay in the hospital after pancreatitis ranged from 2 to 4 days, with a mean length of stay of 2.75 days. The time between SOM and subsequent ERCP ranged from 6 to 20 days, with a mean of 10.4 days. Conclusion By adopting a protocol to perform diagnostic SOM, separate from ERCP and sphincterotomy, we were able to decrease the incidence of pancreatitis considerably at our institutions.

Endoscopic ambulatory surgery centers in the academic medical center: We can do it too!

A freestanding ambulatory surgery center (ASC) at an academic institution is an exception rather than the rule. It is a major challenge to the concept of the traditional academic medical center. Advantages and disadvantages are discussed, as well as the detailed planning process beginning with a well executed feasibility study, the hiring of consultants, and financing of the facility. Construction, opening of the facility and operation are not different from other ACSs. However, the integration of teaching and research presents new opportunities. Lessons learned and advice to others are detailed on how the ASC benefitted one specific institution and how it may add value and revenue to other academic medical centers.

Cystic and tubular congenital duplication of the esophagus: two case reports

Congenital esophageal duplication is a very rare occurrence. The cystic type accounts for the majority of cases, while the tubular type is far less common. We report two cases of congenital esophageal duplication in adults, one of the cystic type and the other of the tubular type.