Philip E. Jaffe

Effect of ambulatory 24-hour esophageal pH monitoring on reflux-provoking activities.

Ambulatory 24-hr esophageal pH monitoring isconsidered the gold standard for diagnosinggastroesophageal reflux disease (GERD). The currentapproach is to encourage patients to pursue theireveryday activity in order to obtain near-physiologicalrecordings. However, the effect of the test itself onreflux-provoking activities has never been evaluated.Thus, the aim of our study was to assess daily foodconsumption, habits, symptoms, sleep, and perceivedexperience of patients undergoing pH testing as comparedto an off test (normal) day. Patients reported type andtime spent in each activity pursued, food ingested and length of each meal, habits, frequency andseverity of GERD and other related symptoms, sleepdisturbances, side effects, and overall perceivedexperience during pH testing and four weeks later,during a normal day. Fifty-four patients enrolled. pHtesting significantly reduced time spent being active,number of meals and cups of coffee consumed, andfrequency of GERD symptoms. Almost half of the patients reported having dysphagia during the test. Mostpatients experienced side effects and stated that thetest bothered them most of the time. In conclusion, pHtesting has a significant effect on decreasing reflux-provoking activities — patientstend to assume a more sedentary lifestyle. This mayinfluence the reliability of the test as a physiologicmeasure of acid reflux.

Clinical presentation and management of iatrogenic colon perforations

BACKGROUND Because iatrogenic colonic perforation is uncommon, surgical management of this complication has been based on the civilian trauma experience. In this study, we determine the incidence, clinical presentation, and management of colonic perforations resulting from colonoscopy or barium enema. PATIENTS AND METHODS The medical records of all patients with colorectal perforations due to barium enema or colonoscopy seen over a 5-year period were reviewed. RESULTS Twenty-one patients, 12 males and 9 females aged 66 +/- 16 years, undergoing evaluation for polyps and bleeding (11), diverticulosis (4), diarrhea (2), or miscellaneous indications (4) sustained colonic perforation from colonoscopy (18; 0.20%) or barium enema (3; 0.10%). Abdominal pain, 66% (13), and fever, 24% (5), were the most frequent symptoms encountered and extraluminal air, 67% (14), the most common radiologic finding. The site of perforation was the rectosigmoid in 62% (13) of patients. Eighteen patients underwent surgery; 11 within 24 hours (group I) and 7 patients within 6.0 +/- 4 days (group II). Fifty percent (9 of 18) had primary repair or resection with anastomosis without mortality. Of the 6 patients initially treated nonoperatively, 3 subsequently underwent surgery. Both deaths, one in group I and one in group II, occurred in patients who had colonic diversion for perforation following colonoscopy. CONCLUSION We conclude that in the absence of significant contamination either primary repair or resection and anastomosis can be performed with acceptable morbidity for iatrogenic perforations of the colon.

Preventing hypoxemia during colonoscopy a randomized controlled trial of supplemental oxygen

Hypoxia as measured by pulse oximetry is well recognized in patients undergoing colonoscopy. A single trial of supplemental oxygen therapy has been shown to diminish the observed desaturation during colonoscopy. We further defined the role of supplemental oxygen during colonoscopy in a randomized controlled trial. Ninety-four patients undergoing routine colonoscopy were randomized to oxygen (2 L by nasal prongs) or placebo (nasal prongs only) arms. The physician and patients were blinded to which arm they were in. Sixty-four percent of patients in the placebo arm desaturated (less than 90% saturation) versus 29% in the treatment arm (p less than 0.001). There were no complications observed in either arm. We conclude that supplemental oxygen will decrease but not prevent the incidence of arterial desaturation observed during colonoscopy.

Endoscopic Ultrasonography: Current Indications and Applications

Endoscopic ultrasonography is an exciting new field, with a rapidly expanding literature describing a wide variety of applications. Despite remarkable advances in the field, a number of crucial issues remain to be resolved. These include the limited availability of educational programs for training, enormous initial start up costs for centers related to the cost of equipment and the lack of interchangeability with processors, paucity of outcomes research studies, and technical limitations of the currently available devices. The aim of this article is to review the basic principles, instrumentation, applications, and potential problems related to endoscopic ultrasound and to attempt to define the realistic role for this tool in contemporary medical practice.

Yield of routine endoscopy beyond the duodenal bulb.

The authors determined the clinical yield, endoscopic time, and patient tolerance of routine upper endoscopy beyond the duodenal bulb. From May through October 1994, all patients undergoing routine esophagogastroduodenoscopy (EGD) were recruited for study. Each procedure was timed from start to finish by the endoscopy nurse, and, in addition, the time of the postbulbar examination was recorded. The endoscopy nurse assessed the patients comfort level when the endoscope was advanced into the duodenal bulb and again at the postbulbar region. A total of 250 EGDs were performed. There were 152 males and 98 females, with a mean age of 57.1 (range, 23-91) years. Indications for the procedure were as follows: gastroesophageal reflux disease symptoms 82, epigastric pain 64, dysphagia 46, Barretts surveillance 25, anemia 23, other research study 16, and other 61. The mean time for the procedure was 11 min and 54 s, whereas the mean time for the postbulbar examination was 46.6 s. Patients tolerated endoscope insertion well both before and during examination of the postbulbar duodenum. The only postbulbar finding that affected clinical management was a postbulbar ulcer in a patient without other ulcers who was positive for Helicobacter pylori. Although routine endoscopic examination beyond the duodenal bulb involves minimal time and is well tolerated by patients, the yield of pathologic findings is low (3.6%) and the yield of findings that alter clinical management even lower (0.4%). In patients without prior GI surgery undergoing routine EGD for indications other than suspected small bowel pathology or active upper GI bleeding, examination of the postbulbar duodenum can be considered an elective part of the procedure.