Stephen E. Silvis

Pseudomonas infection of the biliary system resulting from use of a contaminated endoscope

Pseudomonas aeruginosa was present in bile cultures from 10 patients who had undergone previous endoscopic retrograde cholangiopancreatography in 1984. After environmental cultures and review of instrument disinfection, we traced the infections to a single endoscope contaminated with P. aeruginosa, serotype 10. Although the instrument had been cleaned repeatedly with an automatic endoscope cleaning machine, P. aeruginosa survived on residual moisture left in the channels of the endoscope. Contamination ended only after we began to manually suction alcohol through the endoscope before air drying. In 5 of 10 patients, P. aeruginosa caused clinical infections including gangrenous cholecystitis, abscesses, and death. We could identify no factor that distinguished symptomatic from asymptomatic patients. In asymptomatic patients, P. aeruginosa was recovered from gallbladder bile up to 2 mo after endoscopic retrograde cholangiopancreatography. As this P. aeruginosa epidemic was discovered retrospectively because we monitor bile cultures, we advocate this practice as part of endoscopic retrograde cholangiopancreatography procedures.

The normal cholangiogram.

This paper describes the measurements of the normal cholangiogram as demonstrated by endoscopic retrograde cholangiopancreatography. Two groups of patients were studied. There were 49 patients who had normal livers and no evidence of biliary tract disease. In addition, there were 25 patients with known liver disease and an apparent normal extrahepatic biliary tract. The extrahepatic bile duct was measured in three regions: (1) the common hepatic duct (above the cystic duct and below the bifurcation); (2) the prepancreatic portion (below the cystic duct and above the pancreas); and (3) the interpancreatic portion (bile duct within the pancreas). These measurements ranged from 2.1 to 9.2 mm. Although the common bile ducts were generally quite uniform in caliber, there were instances where each portion was the largest diameter in an individual case. There was a slight increase in bile-duct caliber with age. This study showed somewhat smaller measurements than previously reported and may relate to case selection in this or previous studies.

Cytomegalic inclusion disease diagnosed endoscopically

Two patients who received renal transplants developed erosions or ulcers in the upper gastrointestinal tract. In both cases endoscopic evaluation enabled a diagnosis of cytomegalovirus (CMV) infection to be made quickly and safely. We emphasize the importance of early diagnosis of CMV infection and how endoscopy may be helpful.

Gastric ulceration associated with aspirin ingestion in an achlorhydric patient: A case report

The occurrence of gastric ulceration in the absence of measurable gastric acid secretion is a rare phenomenon. Since the advent of maximal gastric acid stimulation tests, only one case of persistent achlorhydria and benign gastric ulcer has been documented in the literature (1). The patient described below presented with achlorhydria and gastric ulceration. Aspirin rather than acid was suspected to be the significant etiologic agent.

A canine model of gastric and colonic polyps.

Polyps were produced in the canine stomach and colon by a surgical technique. In a total of 18 dogs 26 polyps were produced in the stomach or colon. Twenty of the 26 polyps were viable when endoscopically and microscopically examined. Polyps of approximately 1 cm in diameter and 3 to 4 cm in length can be produced without sloughing. The gross and microscopic characteristics of the canine polyp are quite similar to the human condition. Obviously the adenomatous tissue of the polyp head was not reproduced, but this area is not generally cut during polypectomy. The surgical produced polyps appear to be useful as a model to study the effects of electrosurgical cutting and for training in the technique of polypectomy.

Endoscopic treatment of gastrointestinal bleeding. Topical therapy and variceal injection.

Previous discussion during this consensus exercise has clearly demonstrated the superiority of endoscopy as a diagnostic technique. It has raised the question: Does this increased accuracy of diagnosis translate into improved patient well-being? Since the beginning of endoscopy, the observation of acutely bleeding lesions has raised the possibility of endoscopic therapy. With the advent of modern fiberoptic endoscopes with biopsy channels, an avenue for introducing various instruments into the gastrointestinal tract to control gastrointestinal bleeding has become a reality. The following paper will discuss a conventional mode of controlling bleeding the application of heat by either laser or electrocoagulation. The purpose of this paper is to discuss the other modalities, particularly, topical agents. An ideal endoscopic therapy should produce no further tissue destruction, be effective in both localized and diffuse lesions, be portable, relatively easy to apply, and available through standard instrumentation. The topical agents to be discussed fulfill many of these criterion.

A balloon designed for endoscopic variceal sclerotherapy.

Endoscopic injection of esophageal varices with sclerosing agents is a relatively old technique first reported by Craaford and Frenchner in 1939 and used throughout the 1940s. During its early stages, endoscopic variceal sclerotherapy (EVS) fell into disuse because rigid esophagoscopes required general anesthesia and because of the impression that portacaval shunting was a superior form of therapy. Portal shunting prevents recurrent variceal hemorrhage; however, it is associated with high operative mortality and morbidity from hepatic failure. 4 A resurgence of interest in EVS over the last decade has primarily been due to both the introduction of flexible fiberoptic endoscopy and the unsatisfactory results of surgical intervention. The techniques of EVS vary widely. Currently used balloons range from condoms to modified endotracheal cuffs. Many endoscopists use pneumatic balloons secured to the distal tip of the endoscope in an attempt to improve sclerosant injection and retention time and to enable direct tamponade of varices in the event of bleeding. The use of a balloon in this manner has not been systematically evaluated and has been controversial. One reason for controversy is that no data exist to document the relationship between the measured internal balloon pressure and actual transmission of pressure to the esophageal wall. Variability in pressure transmission may account for variable results. We have measured the actual pressure transmitted to the esophageal wall by balloons and have developed a balloon which transmits pressure on a one-to-one basis.