Takako Maruyama

Autonomic nervous function in upper gastrointestinal endoscopy : a prospective randomized comparison between transnasal and oral procedures

Background. Transnasal esophagogastroduodenoscopy (EGD) using an ultrathin endoscope is less stressful to the cardiovascular system with less elevation of systolic blood pressure (BP) than oral procedures. To elucidate the mechanism of such beneficial cardiovascular responses, we performed a prospective patient-centered randomized study in which BP and pulse rate (P), as well as autonomic nervous functions, were estimated during transnasal EGD compared with those in oral procedures using the same ultrathin endoscope. Methods. The study involved 781 patients, among whom 55 and 56 cases were assigned to transnasal and oral EGD groups, respectively. The autonomic nervous responses were determined employing power spectral analysis (PSA) of heart-rate variations on electrocardiogram. PSA data were based on two peaks in lowfrequency (LF) and high-frequency (HF) ranges. HF power and the ratio of LF power/HF power represented parasympathetic and sympathetic nervous activities, respectively. Results. Our study confirmed the lesser elevation of BP and P in patients undergoing transnasal EGD than in those undergoing oral procedures. PSA revealed a lower increase in LH power/HF power in transnasal EGD than in oral EGD. However, both endoscopic procedures equally suppressed HF power. Significant correlations were found between the parameters of cardiovascular response (P and BP) and autonomic functions (LF power/HF power ratio and HF power). Conclusions. This is the first study demonstrating less sympathetic stimulation in patients undergoing transnasal EGD, leading to lesser elevation of BP and P.

CARDIOVASCULAR TOLERANCE IN UNSEDATED UPPER GASTROINTESTINAL ENDOSCOPY: PROSPECTIVE RANDOMIZED COMPARISON BETWEEN TRANSNASAL AND CONVENTIONAL ORAL PROCEDURES

Background:  The utility of transnasal esophagogastroduodenoscopy (EGD) using ultrathin endoscopy has previously been described by analyzing subjective information and comparing it to conventional oral EGD. Limited information is available regarding the advantageous use of nasal EGD when assessed by reliable objective data.

CARDIOVASCULAR TOLERANCE IN UPPER GASTROINTESTINAL ENDOSCOPY USING AN ULTRATHIN SCOPE: PROSPECTIVE RANDOMIZED COMPARISON BETWEEN TRANSNASAL AND TRANSORAL PROCEDURES

Background:  Transnasal esophagogastroduodenoscopy (EGD) has been suggested to be better tolerated by the cardiovascular system with a lower elevation of systolic blood pressure (BP) than oral EGD. However, limited information is available on the precise comparison of cardiovascular responses between the two endoscopic procedures using the same ultrathin scope.

Impaired autonomic function in type 2 diabetic patients during upper gastrointestinal endoscopy

BackgroundCardiac autonomic neuropathy, representing decreased parasympathetic nerve activity and predominance of sympathetic tone, is often encountered in diabetic patients, and leads to an increased risk of cardiovascular events including arrhythmia. To evaluate the potential cardiovascular risk of diabetics in performing esophagogastroduodenoscopy (EGD), we compared the autonomic function and cardiovascular parameters during EGD between diabetic and nondiabetic patients.MethodsThe autonomic nervous responses in 86 consecutive outpatients (42 type 2 diabetics and 44 nondiabetics) were determined by power spectral analysis (PSA) of heart-rate variations on an electrocardiogram. PSA data were based on two peaks in the low-frequency (LF) and high-frequency (HF) ranges. HF power and the ratio of LF power/HF power represented parasympathetic and sympathetic nerve activities, respectively.ResultsDiabetic patients showed significantly lower ΔHF power and significantly higher ΔLF power/HF power than nondiabetics, suggesting enhanced predominance of sympathetic activity and marked suppression of parasympathetic function. Significant correlations were found between these autonomic parameters and the diabetic duration. A slightly higher incidence of ventricular premature contractures was observed in diabetics during EGD. However, no significant difference was found in pulse or blood pressure increments during EGD between the two groups.ConclusionsThis is the first study demonstrating an imbalance of autonomic function in diabetics during EGD, which may be linked to a slightly higher risk of arrhythmia.

Multiple hepatic pseudotumors on sonography

To the Editor: Hepatic pseudotumors mimicking metastatic disease detected on ultrasonography are usually located in a specifi c part of the liver. For instance, hypoechoic pseudotumors found in the fatty liver are frequently located in the gall bladder fossa or anterior part to the portal vein.1 On the other hand, hyperechoic pseudotumors due to focal fatty infi ltration are found mainly in the medial segment of the left lobe.2 However, such pseudotumors usually do not spread over the liver.3 We have experienced a rare case of multiple hyperechoic pseudotumors spreading to the whole liver. A 58-year-old man, who drank approximately 550 ml of sake (50 g of ethanol) a day, visited us for a liver function test. Blood analyses showed an increase in α-glutamyl transpeptidase (163 IU/ l), but other liver function data as well as complete blood cell counts were within normal limits. Tumor markers including αfetoprotein (5.9 ng/ml), carcinoembryonic antigen (4.2 ng/ml), and carbohydrate antigen 19-9 (6.2 U/ml) were also in the normal range. Ultrasonography showed a number of high-echogenic ovalshaped areas with diameters of around 1 cm throughout the liver (Fig. 1A). Computed tomography (CT) demonstrated the presence of multiple low-density areas (Fig. 1B) that were slightly enhanced in the arterial phase (Fig. 1C) and then enhanced equally in the surrounding tissues in the subsequent portal phase of the dynamic study (data not shown). Similar fi ndings were obtained when the patient was examined by CT hepatic arteriography and CT arterial portography. No remarkable fi nding was obtained when he was examined by magnetic resonance imaging (MRI) or positron emission tomography. Sonographically guided biopsy specimens showed slight fatty degeneration of hepatocytes (Fig. 1D). The follow-up sonographic examination after 12 months showed little change in the shape of pseudotumors. Nodular parenchymal fatty infi ltration has been reported as a cause of the hyperechogenicity of most pseudotumors.1–3 Nonportal venous supply to the liver has been suggested to contribute to focal fat deposits.4 However, in the present case, only a slight fatty change was observed in the biopsy specimens, and thus the histological background of the echogenicity remains to be further elucidated. Multifocal pseudotumors mimicking metastatic tumors are sometimes encountered on diagnostic modalities including ultrasonography, CT, and MRI.5 Confi rmation of diagnosis often requires invasive procedures, and thus such lesions are still of clinical relevance. The present case may be informative for diagnosing multiple tumorous lesions of the liver.

A novel technique for the internal drainage of extrahepatic biloma complicating transarterial embolization of hepatocellular carcinoma

Biloma is an infrequent complication of nonsurgical treatments of hepatocellular carcinoma (HCC), including transarterial embolization (TAE), and it is often associated with ischemic injuries of the biliary tract after therapy. We here report on a case featuring successful internal drainage of an extrahepatic biloma into the duodenum by a route via the cholecyst, cholecystic duct, and common bile duct under fluoroscopic control. An extrahepatic biloma developed after urgent TAE for ruptured HCC and became contaminated. Radiography with contrast medium through the percutaneous drainage tube revealed a fistula between the biloma and gallbladder. The drainage catheter was introduced into the gallbladder through the fistula, from where it subsequently reached the duodenum via the cholecystic and common bile ducts. The internal drainage route played a major role in the rapid elimination of the biloma, which did not recur after the tube was withdrawn. To our knowledge, this is the first report of internal drainage of a biloma through the cholecystic and common bile ducts.