Jim T. Schwartz

Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus.

We prospectively compared the efficacy of polyvinyl bougies (Savary type) passed over a guide wire and through-the-scope balloons for the dilation of peptic esophageal strictures in a randomized study. Thirty-four patients, 17 in each treatment arm, were studied. At entry, dysphagia was assessed according to a six-point scale (0, unable to swallow; 5, normal). The end-point for dilation was to size 45F or 15 mm. Discomfort during the procedure was graded on a four-point scale (0, no discomfort; 1, mild; 2, moderate; 3, severe discomfort). Follow-up visits were at 1 week, 1 month, 3 months, and every 3 months thereafter for 2 years. At the 1-week visit, the size of esophageal lumen was measured by 8-, 10-, and 12-mm pills. Both devices effectively relieved dysphagia. By life-table analysis, stricture recurrence during the first year of follow-up was similar in both groups, but during the second year, the risk of recurrence was significantly lower in patients whose strictures were dilated with balloons. Other advantages of balloons included the need for fewer treatment sessions to achieve the defined end-diameter for dilation (1.1 + 0.1 versus 1.7 + 0.2, p < .05), and less procedural discomfort (p < .05). The differences in luminal size after dilation, measured by the barium pill test, were not significant. Ability to pass the 12-mm pill and absence of dysphagia were correlated. Our results indicate that both devices are effective in relieving dysphagia, but balloons may have a long-term advantage.

Toothpick perforation of the intestines.

Toothpicks have been used since antiquity as instruments for mouth cleansing and as eating utensils. Toothpick injury to the gastrointestinal tract is often suspected only at the time of operation because patients rarely relate a history of swallowing toothpicks and most toothpicks are not radiopaque. The spectrum of toothpick injury to the gastrointestinal tract is illustrated by 5 patients who developed toothpick perforation of the gastrointestinal tract. Two patients died as a result of complications of toothpick injury, one of these presenting with recurrent gram negative sepsis with multiple organisms due to a duodenal-inferior vena caval toothpick fistula. In two instances the toothpicks were removed at operation and one that was penetrating the duodenum was removed with a fiberoptic duodenoscope.

The spectrum of the Mallory-Weiss tear.

A Mallory-Weiss tear is a mucosal laceration occurrring at or near the esophagogastric junction and is most often associated with vomiting. This is a common cause of upper gastrointestinal bleeding; in our series, 14% of patients presenting to the hospital because of upper gastrointestinal bleeding had Mallory-Weiss tears. Massive hemorrhage is not characteristic and 37% of the patients required no blood transufsions. A classical history of nonbloody emesis followed by hematemesis was found in only 29% of patients. The most common story was the appearance of blood with the first vomiting. In 35% of our patients with Mallory-Weiss tear, an additional potential bleeding site was identified, and, in approximately half of these patients, it was actually bleeding. Most Mallory-Weiss tears stop bleeding spontaneously and supportive treatment is all that is required. If bleeding continues, infusion of vasoactive substances into the celiac artery or into the left gastric artery often obviates the need for operation.

Evaluation of the effectiveness of through-the-scope balloons as dilators of benign and malignant gastrointestinal strictures

Although the true place of balloon dilators in our armamentarium of methods for the management of gastrointestinal strictures is not yet known, balloons are now widely used.26 Balloons have been used for a variety of gastrointestinal stenoses including esophageal,1-19 gastric,16-23 small intestinal,24 and colonic25,26 strictures. Balloon dilatation offers many theoretical advantages (safety, speed, and patient comfort) over dilatation with mercury-filled bougies or with the Eder-Puestow or Savary systems. Recently, the availability of large diameter balloon dilators (Fig. 1), which pass through the biopsy channel of standard endoscopes (through-the-scope or TTS balloons), has promised efficient direct-vision dilatation of strictures without the need of guide wires or fluoroscopy. We prospectively evaluated whether dilatation with TTS balloons actually achieved the expected luminal diameter in benign and malignant gastrointestinal strictures.

The significance of "indefinite for dysplasia" grading in Barrett metaplasia

CONTEXT For a confident diagnosis of dysplasia in Barrett metaplasia, the epithelial atypia should also involve the surface epithelium. However, pathologists are often faced with biopsies where the crypts show dysplasia, but the surface epithelium is either uninvolved or unevaluable. We previously grouped these cases with indefinite for dysplasia (IND). OBJECTIVE To determine the clinical significance of IND grading in Barrett metaplasia. DESIGN All biopsies from 276 prospectively followed patients with Barrett metaplasia, who did not have high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) on initial biopsy, were graded as negative for dysplasia, IND, low-grade dysplasia (LGD), HGD, and EAC. Biopsies with multifocal IND or LGD were graded as INDM or LGDM, respectively. RESULTS Only 3 of 193 patients (2%) with an initial diagnosis of negative for dysplasia and only 1 of 48 patients (2%) diagnosed with IND progressed to HGD or EAC. By contrast, 1 of 7 patients (14%) with INDM, 2 of 21 (10%) with LGD, and 1 of 7 (14%) with LGDM progressed to HGD or EAC. There was no significant difference in progression rate between patients with an initial diagnosis of negative for dysplasia and those diagnosed IND nor were there significant differences among patients with initial diagnoses of INDM, LGD, or LGDM. Kaplan-Meier analysis showed that patients with INDM, LGD, or LGDM on initial biopsy (group 1) were more likely to progress to HGD or EAC than were those patients who were diagnosed negative for dysplasia or IND (group 2; log-rank test, P < .001). CONCLUSIONS Multifocal IND in an esophageal biopsy from a patient with Barrett metaplasia has the same clinical implication as LGD.

Goblet Cell Mimickers in Esophageal Biopsies Are Not Associated With an Increased Risk for Dysplasia

CONTEXT Identification of intestinal-type goblet cells (ITGCs) in hematoxylin-eosin-stained sections of esophageal biopsies is essential for the diagnosis of Barrett metaplasia. However, we have seen cases diagnosed as Barrett metaplasia based solely on cells that pose morphologic similarity to ITGCs on hematoxylin-eosin staining or stain positive with Alcian blue. OBJECTIVE To determine the clinical significance of goblet cell mimickers. DESIGN Initial biopsies from 78 patients with original diagnosis of Barrett metaplasia negative for dysplasia and a mean follow-up of 72 months were reviewed and reclassified into 3 categories: (1) ITGCs, (2) goblet cell mimickers, or (3) neither. Sections from available paraffin blocks were stained with Alcian blue at pH 2.5. The presence of the different types of cells and positive Alcian blue staining were correlated with each other and evaluated for their significance as predictors of progression to dysplasia. RESULTS Goblet cell mimickers were present in 35 cases and were associated with ITGCs in the same biopsy in 23 (66%) of these cases. Intestinal-type goblet cells were present in 56 cases, and the remaining 10 cases, although called Barrett on the original report, did not show either ITGCs or goblet cell mimickers. Only the presence of ITGCs was associated with significant risk for dysplasia (P = .008). Positive Alcian blue staining was not associated with a significant risk for dysplasia. CONCLUSIONS Our results indicate that the diagnosis of Barrett metaplasia should be rendered with confidence only when ITGCs are identified on routine hematoxylin-eosin-stained sections.

Endoscopic needle biopsy: a comparative study of forceps biopsy, two different types of needles, and salvage cytology in gastrointestinal cancer

One of the goals of gastrointestinal endoscopy is to diagnose whether a lesion is malignant. The desire to improve the sensitivity of biopsy-sampling techniques prompted us to compare prospectively the reliability and accuracy of obtaining tissue by forceps biopsy, needle biopsy (21 gauge 13-mm long metal needles versus 18 gauge 20-mm long plastic needles), and salvage cytology in patients with endoscopically suspected malignancy. Samples were obtained in the order of needle biopsy (the order of metal and plastic needle biopsy was randomized), forceps biopsy, followed by salvage cytology. Needle biopsies were obtained by puncturing the lesion under direct vision while aspirating with a syringe. Twenty-three patients with gastrointestinal malignancy were studied (7 esophageal, 4 gastric, and 12 colonic). Forceps biopsies were positive in 18 of 23 (78%), missing 1 gastric and 4 colon malignancies. Metal needle biopsy was positive in 16 of 19 (84%), plastic needle biopsy in 17 of 22 (77%), and salvage cytology in 20 of 22 (91%). Accuracy was increased by a combination of techniques. Endoscopic needle biopsy is a simple and rapid method to evaluate lesions seen at endoscopy and is especially useful in evaluation of submucosal lesions.

Ranitidine and Hepatotoxicity

Excerpt To the editor: Two articles in the August issue reported liver injury possibly associated with the use of ranitidine. Lima (1) reported a well-documented case of ranitidine hepatitis, prove...

Avoiding infliximab in the treatment of Crohn's disease in patients with multiple sclerosis

Avoiding infliximab in the treatment of Crohns disease in patients with multiple sclerosis

Nonpathogenic nematodes in gastrointestinal aspirates obtained during endoscopy

The gastroenterologist must be alert to diagnosing parasitic diseases when collecting intestinal fluid samples or cytologies during endoscopy. Between 1979 and 1982, we identified nematodes in 10 endoscopic specimens. None were Strongyloides stercoralis. We emphasize the importance and technical aspects of distinguishing nonpathogenic nematodes from Strongyloides.