Mitchell S. Cappell

A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up of fetal outcome and with comparison to control groups.

To analyze the risks versus benefits of flexible sigmoidoscopy and colonoscopy to the pregnant female and fetus, we conducted a multiyear, retrospective study at 10 hospitals of 46 patients undergoing 48 sigmoidoscopies and 8 patients undergoing 8 colonoscopies during pregnancy. Sigmoidoscopy controls included two study control groups and the average American pregnancy outcomes. Sigmoidoscopy indications included hematochezia in 28, diarrhea in 10, abdominal pain in 4, and other in 3. Thirteen patients were in the first trimester of pregnancy, 18 were in the second trimester, and 15 were in the third trimester. Twenty-seven patients had a lesion diagnosed by sigmoidoscopy, including reactivated or newly diagnosed inflammatory bowel disease, bleeding internal hemorrhoids, and other colitidies. Twenty-two of 29 patients with rectal bleeding had a significant lesion identified by sigmoidoscopy. Sigmoidoscopy was significantly more frequently diagnostic for hematochezia than for other indications (p < 0.03, χ2). No endoscopic complications occurred to the pregnant patients. Excluding 4 voluntary abortions and 1 unknown pregnancy outcome, 38 (93%) of 41 pregnant females delivered healthy babies (study control rate=93%; NS, Fishers exact test). Mean live-born infant Apgar scores were 8.2 ± 1.5 (SD) at 1 min and 9.0 ± 0.2 at 5 min (control mean Apgar scores: 8.1 ± 1.7 at 1 min and 8.8 ± 1.0 at 5 min; NS, Studentst test). Three high-risk pregnancies ended with fetal demise at 8, 9, or 12 weeks after sigmoidoscopy, from causes unrelated to sigmoidoscopy. No fetal cardiac abnormalities were detected by fetal cardiac monitoring during two sigmoidoscopies. Eight pregnant females underwent colonoscopy, without complications. Pregnancy outcomes included six healthy babies delivered at full term, one voluntary abortion, and one fetal demise in a high-risk pregnancy 4 months after colonoscopy from causes unrelated to colonoscopy. This study suggests that sigmoidoscopy does not induce labor or result in congenital malformations, that sigmoidoscopy is not contraindicated during pregnancy, and that sigmoidoscopy may be beneficial in pregnant patients with significant lower gastrointestinal bleeding. Colonoscopy during pregnancy should be considered for life-threatening lower gastrointestinal bleeding or when the only alternative is surgery.

INTESTINAL (MESENTERIC) VASCULOPATHY I: Acute Superior Mesenteric Arteriopathy and Venopathy

Intestinal vasculopathy is not rare, comprising about 1 per 1000 hospital admissions. Primary mesenteric vasculopathy causes cardiovascular disease, whereas secondary mesenteric ischemia causes extrinsic vascular compression or vascular trauma. Acute superior mesenteric arteriopathy is caused by a mesenteric embolus, thrombus, or vasospasm (i.e., nonocclusive vasculopathy). Acute superior mesenteric venopathy is caused by a thrombus, which is often associated with a hypercoagulopathy. The clinical presentation of both diseases is often subtle and nonspecific at an early stage and becomes overt and specific only when advanced and severe, when ischemia progresses to necrosis. The mortality of acute superior mesenteric arteriopathy is still very high, whereas superior mesenteric venopathy is less rapidly progressive and has a lower, but still significant, mortality. Early diagnosis and aggressive therapy significantly reduces the mortality of these life-threatening diseases.

Colonic toxicity of administered drugs and chemicals

Although uncommon, medication-induced colonotoxicity is important to recognize because medication cessation generally leads to prompt clinical improvement, while medication continuation results in disease exacerbation. This review categorizes the association between medications and colonotoxicity as “well-established” or “probable,” according to the following criteria: total number of reported cases, number of different research groups reporting an association, experimental and pharmacologic evidence of an association, and validity of an association in each reported case. Cocaine, ergotamine, estrogen, sodium polystyrene, alosetron, amphetamines, pseudoephedrine, and vasopressin are associated with colonic ischemia. The mechanisms include vasospasm, thrombogenesis, and shunting of blood from mesenteric vessels. Narcotics, phenothiazines, vincristine, atropine, nifedipine, and tricyclic antidepressants are associated with colonic pseudo-obstruction. The mechanisms include antagonizing prokinetic neurotransmitters, stimulating antikinetic neurotransmitters, promoting dysmotility, relaxing smooth muscle, and injuring enteric neurons. Numerous antibiotics are associated with pseudomembranous colitis; ampicillin is associated with hemorrhagic colitis; chemotherapy is associated with neutropenic colitis; and deferoxamine is associated with Yersinia enterocolitis. Mechanisms of these toxicities include altering normal bowel flora, weakening immunologic defenses, promoting microorganism virulence, and mucosal injury. Gold compounds, nonsteroidal antiinflammatory drugs, alpha-methyldopa, salicylates, and sulfasalazine are associated with an inflammatory or cytotoxic colitis. The mechanisms include direct mucosal cytotoxicity, antimetabolite effects, or drug allergy. Nonsteroidal antiinflammatory drugs, cyclo 3 fort, flutamide, lansoprazole, and ticlopidine are associated with lymphocytic colitis. The mechanisms include immunologic activation or attenuated immunologic defenses. Chronic cathartic use leads to colonic hypomotility and abdominal distention. Intrarectally administered corrosive compounds can produce a toxic colitis.

Acute Pancreatitis: Etiology, Clinical Presentation, Diagnosis, and Therapy

Acute pancreatitis is a relatively common disease that affects about 300,000 patients per annum in America with a mortality of about 7%. About 75% of pancreatitis is caused by gallstones or alcohol. Other important causes include hypertriglyceridemia, medication toxicity, trauma from endoscopic retrograde cholangiopancreatography, hypercalcemia, abdominal trauma, various infections, autoimmune, ischemia, and hereditary causes. In about 15% of cases the cause remains unknown after thorough investigation. This article discusses the causes, diagnosis, imaging findings, therapy, and complications of acute pancreatitis.

Abdominal pain during pregnancy

Numerous medical, surgical, psychiatric, gynecologic, and obstetric disorders can cause abdominal pain during pregnancy. The patient history, physical examination, laboratory data, and radiologic findings usually provide the diagnosis. The pregnant woman has physiologic alterations that affect the clinical presentation, including atypical normative laboratory values. Abdominal ultrasound is generally the recommended radiologic imaging modality; roentgenograms are generally contraindicated during pregnancy because of radiation teratogenicity. Concerns about the fetus limit the pharmacotherapy. Maternal and fetal survival have recently increased in many life-threatening conditions, such as ectopic pregnancy, appendicitis, and eclampsia, because of improved diagnostic technology, better maternal and fetal monitoring, improved laparoscopic technology, and earlier therapy.

Characterization of Bouveret's syndrome: a comprehensive review of 128 cases.

AIM:The aim of the study was to characterize the clinical presentation, evaluation, and therapy of Bouverets syndrome, by comprehensively reviewing all the identified previously reported cases, to facilitate early diagnosis and thereby to improve the prognosis.METHODS:Relevant articles were identified by MEDLINE computerized searches, by consultation with all available reference books, and by review of the first authors teaching files. A new case in which the diagnosis of Bouverets syndrome was missed at esophagogastroduodenoscopy (EGD)—despite endoscopic findings of gastric outlet obstruction caused by a hard, nonfleshy, and convex pyloric mass—prompted this review.RESULTS:Review of 128 reported cases identified syndromic characteristics. Patients on average were 74.1 ± 11.1 (SD) yr old. The female-to-male sex ratio was 1.86. Prominent symptoms were nausea and vomiting in 87%, abdominal pain in 71%, hematemesis in 15%, recent weight loss in 14%, and anorexia in 13% of patients. Prominent signs were abdominal tenderness in 44%, signs of dehydration in 31%, and abdominal distention in 26% of patients. Endoscopy revealed gastroduodenal obstruction in nearly all cases, but identified the obstructing stone in only 69%. Abdominal ultrasound or computerized tomography was diagnostic in about 60% of cases.CONCLUSIONS:The following endoscopic findings are suggestive of Bouverets syndrome: a dilated stomach containing old digested food from gastrointestinal obstruction together with a hard and nonfleshy mass at the obstruction. These endoscopic findings, in the setting of the currently reported characteristic epidemiologic and clinical findings, should strongly suggest this syndrome. Abdominal ultrasound or computerized tomography is recommended to confirm and extend the endoscopic diagnosis.

Cessation of Recurrent Bleeding from Gastrointestinal Angiodysplasias After Aortic Valve Replacement

Recurrent bleeding from gastrointestinal angiodysplasias associated with aortic stenosis ceased after aortic valve replacement in two patients. In one patient numerous gastrointestinal angiodysplasias disappeared, as shown by endoscopy, after aortic valve replacement. Valve replacement may be adequate treatment for gastrointestinal bleeding from angiodysplasia associated with aortic stenosis. Elective surgery for angiodysplasias should be postponed until after a trial period to ascertain whether bleeding stops after valve replacement.

Risk Factors and Risk Reduction of Malignant Seeding of the Percutaneous Endoscopic Gastrostomy Track from Pharyngoesophageal Malignancy: A Review of all 44 Known Reported Cases

AIM:To comprehensively review all known reported cases of stomal metastases after percutaneous endoscopic gastrostomy (PEG) to systematically identify risk factors for this complication and to develop strategies for reducing this risk.METHODS:Reported cases were identified by computerized literature searches. Criteria for risk factors for stomal metastases included: a substantially higher relative rate of this factor in patients with stomal metastases than expected from pharyngoesophageal malignancy in general, and biologic plausibility of this phenomenon.LITERATURE REVIEW:Review of all 44 known stomal metastases revealed the following. The mean patient age was 59.0 ± 10.0 (SD) yr, and 79% of patients were male. Pathologically proven stomal metastases were located in the abdominal wall (PEG exit site) in 63%, in the gastric wall (PEG entrance site) in 7%, and in both walls in 30%. Mean survival after diagnosis was only 4.3 ± 3.8 months. Pathologic risk factors for stomal metastases included: (a) pharyngoesophageal location of primary cancer (in 100% of cases, 0% other locations); (b) squamous cell histology (in 98%, adenocarcinoma in 2%); (c) poorly or moderately differentiated histology (in 92%, well differentiated in 8%); (d) advanced pathologic stage (in 97%, early stage in 3%); and (e) large primary cancer size at diagnosis (mean diameter 4.2 ± 2.3 cm). These risk factors appeared to be quantitatively large (e.g., 98% of cases had squamous histology vs 50% expected rate, odds ratio 40.1, OR CI 6.31–246.4, P < 0.0001). Therapeutic risk factors for stomal metastases included: (a) endoscopic PEG placement (in 98%, surgical gastrostomy in 2%); (b) pull-string PEG technique (in 98%, push-guidewire in 2%, direct-introducer in 0%); (c) primary cancer untreated or known local recurrence after treatment before PEG (in 87%); and (d) time ≥3 months after PEG insertion (in 100%, <3 months in 0%; mean interval 7.8 ± 5.2 months after PEG). Four of the currently reported risk factors are novel (pathologic factors d,e; therapeutic factors a,d).CONCLUSIONS:Strong risk factors for stomal metastases include: pharyngoesophageal primary cancer, squamous cell histology, less well-differentiated cancer, large size, and advanced cancer stage. The risk may be reduced in patients with risk factors by radiotherapy, chemotherapy, or cancer surgery before PEG; by substituting the push-guidewire for the pull-string technique for PEG; and possibly by use of a sheath with the pull-string technique.

INTESTINAL (MESENTERIC) VASCULOPATHY II: Ischemic Colitis and Chronic Mesenteric Ischemia

Ischemic colitis accounts for approximately half of all cases of mesenteric vasculopathy. The clinical presentation varies depending on underlying cause, extent of vascular obstruction, rapidity of ischemic insult, degree of collateral circulation, and presence of comorbidity. Ischemic colitis is usually diagnosed by colonoscopy. Only approximately 20% of patients require surgery because of signs or laboratory findings of peritonitis or because of clinical deterioration. Approximately 20% of patients develop chronic colitis from irreversible colonic ischemic injury, which manifests clinically as persistent diarrhea, rectal bleeding, or weight loss and endoscopically as a colonic stricture or mass. Chronic mesenteric ischemia is almost always caused by significant atherosclerotic stenosis involving at least two mesenteric arteries, usually the superior mesenteric artery and celiac axis. The classic symptomatic triad of postprandial pain, fear of eating, and involuntary weight loss occurs with advanced disease.

The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy.

More than 12,000 pregnant patients in the United States per annum have conditions that are normally evaluated by EGD. More than 6000 pregnant patients in the United States per annum have conditions that are normally evaluated by sigmoidoscopy or colonoscopy. About one thousand more have symptomatic choledocholithiasis during pregnancy, which is a strong indication for endoscopic sphincterotomy in nonpregnant patients. Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal endoscopic risks. Safety of EGD during pregnancy has been examined in a case-controlled study of 83 patients, a mailed survey of 73 patients, and 28 case reports. Safety of sigmoidoscopy during pregnancy has been examined in a case-controlled study of 46 patients, a mailed survey of 13 patients, and 10 case reports. Safety of therapeutic ERCP during pregnancy has been analyzed in studies of 23, 10, 6, and 5 patients, and in 32 case reports. These studies suggested that EGD, sigmoidoscopy, and ERCP should be performed when strongly indicated: EGD for significant upper gastrointestinal bleeding, sigmoidoscopy for nonhemorrhoidal rectal bleeding, and ERCP for symptomatic choledocholithiasis when sphincterotomy is contemplated. PEG and colonoscopy are currently considered experimental during pregnancy because of insufficient data on fetal safety. Several cases of PEG and colonoscopy were successfully performed during pregnancy. Performance of endoscopy during pregnancy should increase with further technical refinements, and greater awareness of procedure safety.