Walter Trudeau

Endoscopic injection sclerosis in bleeding gastric varices

Ninety-two consecutive, nonrandomized patients with bleeding varices were prospectively studied using sclerotherapy to control and prevent rebleeding. During this study, nine patients with gastric variceal bleeding were identified. A gastric variceal subset is defined and represents a 10% incidence in this series. All patients presented with indexed gastric bleeding varices that subsequently accounted for 34 bleeding sessions. The units of blood per rebleeding episode, hospital days, cost, and outcome were markedly different from the esophageal variceal groups. Initial management of indexed bleeding episodes by sclerotherapy and Sengstaken-Blakemore tubes were comparable; however, the number of rebleeding episodes was much higher. There was poor control of rebleeding with an associated higher rebleeding mortality and complications secondary to repeated sclerotherapy and Sengstaken-Blakemore tube use. In 37% of the patients, rebleeding was the direct result of gastric ulcerations at the endoscopic injection sclerotherapy site. The survival curve of this group was much lower than esophageal variceal bleeders. Endoscopic injection sclerotherapy in patients with bleeding gastric varices offers only temporary control of bleeding, and the high incidence of severe early rebleeding requires consideration of alternative methods for management or modified sclerotherapy techniques.

Endoscopic evidence of mucosal injury in patients taking ticlopidine compared with patients taking aspirin/nonsteroidal antiinflammatory drugs and controls

Background Ticlopidine is a novel antiplatelet agent used alone or in combination with aspirin and anticoagulants in the treatment and prevention of various vascular diseases. Gastrointestinal side effects, including bleeding, have been reported with use of ticlopidine in most of the vascular prevention trials. We studied the endoscopic evidence of mucosal damage in patients taking ticlopidine compared with patients taking aspirin/nonsteroidal antiinflammatory drugs (NSAIDs) and matched controls. Study We performed a longitudinal review of gastrointestinal endoscopy, pharmacy databases, and medical records of patients referred to our service over a period of 6 months for endoscopic evaluation of upper gastrointestinal bleeding, unexplained anemia, or abdominal pain. Data were collected and analyzed for 55 patients taking ticlopidine, 77 age- and gender-matched patients taking aspirin or NSAIDs, and 560 age- and gender-matched control patients not taking any of these medications. Results The overall prevalence of ulcers was marginally higher in the aspirin/NSAID group than in the ticlopidine group (35% vs. 29%) and was significantly higher among patients taking aspirin, NSAIDs, or ticlopidine than among controls (15%). Gastritis was also noted more frequently in the aspirin/NSAID and ticlopidine groups than in the control group. Endoscopic evidence of esophagitis was significantly more frequent in the control group than in the aspirin/NSAID and ticlopidine groups. There was no significant difference across groups in the prevalence of ulcers, gastritis, or esophagitis. Conclusions Patients taking ticlopidine are more likely to have endoscopic evidence of mucosal damage than matched control patients and are nearly as likely to have such damage as endoscopically evaluated patients taking aspirin or NSAIDs. However, these findings must be confirmed using prospective cohort data for patients in primary care settings, to avoid referral bias.

A comparison of immediate versus delayed endoscopic injection sclerosis of bleeding esophageal varices

The authors report their experience with immediate endoscopic injection sclerosis at the time of diagnosis of active bleeding esophageal varices compared to delayed sclerotherapy performed after control of variceal bleeding with vasopressin and Sengstaken-Blakemore tamponade. Twenty-eight active index bleeders and 20 active rebleeders were treated by immediate endoscopic injection sclerosis, which could technically be performed on all of the former and in 18 of the rebleeders (96%). Immediate control of active bleeding was achieved in all patients whose varices were injected (100%). Control at 48 hours was 89% for the index bleeding group and 80% for the rebleeding group. In the delayed sclerotherapy group of 19 patients, initial control (79%) and 48-hour control (64%) were significantly less. The rebleeding rate, complications, and death from exsanguination were greater in the delayed group, whereas longevity was similar in both groups. We conclude that immediate sclerotherapy effectively controls acutely bleeding esophageal varices with a lower complication rate than sclerotherapy performed after conventional medical therapy with vasopressin and Sengstaken-Blakemore tube tamponade.

Bacterial peritonitis following esophageal injection sclerotherapy for variceal hemorrhage

Patients presenting with ascites and upper gastrointestinal hemorrhage were studied prospectively. Five patients presenting with acute variceal hemorrhage were found not to have pre-existing spontaneous bacterial peritonitis on initial paracentesis. However, three of these five developed findings compatible with bacterial peritonitis after sclerotherapy. Although the number of cases is small, our results support the monitoring of ascitic fluid after sclerotherapy.

Goodness-of-fit and local identifiability of a receptor-binding radio-pharmacokinetic system

A four-state nonlinear model describing a radiopharmacokinetic system for a hepatic receptor-binding radiopharmaceutical, (/sup 99m/Tc)-galactosyl-neoglycoalbumin, (TcNGA), was tested for goodness-of-fit and local identifiability using scanning data from nine healthy subjects and seven patients with severe liver disease. Based on standard deviations of liver and heart imaging data at equilibria as a measure of observational error, the reduced chi-square ranged from 0.5 to 2.6. Values above 1.2 occurred when the subject moved during the 30 min study. Relative standard errors for each parameter were determined. The highest standard errors occurred when the amount of TcNGA injected exceeded the total amount of receptor. Therefore, when TcNGA functional imaging was performed without excess patient motion and receptor saturation, the kinetic model provided data fits of low systematic error and yielded high precision estimates of receptor concentration and forward binding rate constant.<<ETX>>

Gastrointestinal hemorrhage consequent to foreign body reaction to silk sutures: case series and review

Surgery of the gastrointestinal tract often involves the use of sutures, particularly for luminal re-anastomosis. Nonabsorbable silk sutures or absorbable sutures may be used, depending on the surgeon’s preference. Nonabsorbable sutures, regardless of their original location, have a tendency to migrate toward the luminal surface1 and are often seen during routine endoscopy. However, complications attributed to nonabsorbable sutures used during surgery of the bowel are uncommon. Symptoms attributed to nonabsorbable sutures that have been remedied by endoscopic suture removal include pain, nausea, and vomiting.2 Suture line ulceration, first recognized as a distinct entity by Paterson in 1909,3 is the lesion reported to be responsible for these symptoms. Development of endoscopic technology allowed Small et al.1 in 1968 to estimate that 0.3% of 1008 postgastrectomy patients develop such lesions. A later European series suggested that 153 of more than 600 such patients had ulcerations, 38% being associated with sutures.4 Cotton et al.5 noted that of 20 patients with anastomotic ulcers, 7 had associated sutures. Silk and green Mersilene sutures, both continuous and interrupted, have been implicated in ulceration at gastric anastomoses.6 Histologically, the suture line ulceration has been characterized by a foreign body type reaction, with giant cell infiltration and fibrosis7 and dense capillary proliferation in some.8 Occult blood in the stool, and more uncommonly melena, have been noted in patients with suture line ulceration.1,3,9 Massive upper gastrointestinal hemorrhage related to suture line ulceration is apparently rare but has been reported.7 One patient developed bleeding 2 years after surgery10; another patient with end-stage renal disease had suture line ulceration documented by endoscopy.11 Tanner’s experience during World War II with bleeding associated with silk sutures used in gastric surgery prompted his strong recommendation against their use.12 Recognition of these complications of silk suture material may allow for timely removal either endoscopically or surgically as first reported by Classen and Roesch.13 We report three cases of recurrent upper gastrointestinal hemorrhage after partial gastrectomy related to the use of silk sutures that were not associated with endoscopically evident mucosal ulceration and review the literature concerning this complication as well as the tissue reaction to injury and foreign bodies resulting in rich local microvascularity.

Outpatient endoscopic injection sclerosis of esophageal varices

We report our experience with outpatient endoscopic injection sclerosis (EIS). Fourteen patients receiving elective in patient EIS (30 patient sessions) were compared to 34 patients having elective outpatient EIS (133 patient sessions). The majority of the patients had Childs C alcoholic liver disease. There were two major complications in the 14 inpatients receiving elective EIS, one severe hemorrhage and one death, for a complication rate of 14%. There were no minor complications in this group. In the 34 patients undergoing outpatient EIS there was one major complication for a complication rate of 2.9% (bleeding) and no deaths. Minor complications in the outpatient group included chest pain in 9.0%, dysphagia without stricture in 6.0%, severe ulceration precluding EIS in 21.0%, and stricture of esophagus in 24.0%. The average cost for inpatient EIS was +1183.00 and for outpatient EIS, +339.00.

Hepatic uptake of [99mTc]galactosyl-neoglycoalbumin is sensitive to receptor quantity

[Technetium-99m]galactosyl-neoglycoalbumin (TcNGA) is a synthetic radioligand specific to the receptor, hepatic binding protein (HBP), which resides exclusively at the cell surface of hepatocytes. If the TcNGA time-activity data are to provide valid estimates of receptor biochemistry via pharmacokinetic modeling, the shape of the hepatic uptake curve must change with alterations in receptor concentration or affinity. An index of TcNGA hepatic uptake, T90, was obtained by calculating the time at which the liver time-activity curve reached 90% of its maximum. Receptor quantity was measured by Scatchard binding assay of liver biopsy samples obtained prior to each TcNGA study. The range of T90 was 3.7-16.8 min; HBP quantity ranged from 0.022 to 0.100 mumol. Significant correlation (r) and slope (b) was observed between T90 and HBP quantity (r = 0.82, P = 0.003; tb = 3.98, P = 0.003). We concluded that the hepatic uptake of TcNGA is sensitive to HBP quantity.

Manifestations of Crohn's Disease

Accessible online at: http://BioMedNet.com/karger Fig. 1. A 62-year-old female with a history of Graves’ disease and fistula in ano presented to the emergency room with a 1-month history of bloody diarrhea, fever, chills, night sweats, and fatigue. On physical examination she was febrile to 38.5°C and had multiple lingual (a), gingival (b) oral ulcers, and vulvar ulcers. Ophthalmologic examination showed no uveitis. Laboratory data were significant for a hematocrit of 26% (normal 35–45), a mean corpuscular volume of 71 (normal 80–96), and a white blood cell count of 8.7/mm3 (normal 3.2–9.8). Erythrocyte sedimentation rate was 1140 mm/h (normal 0–15). Stool studies showed numerous fecal leukocytes, but no ova or parasites. Stool culture was negative for Salmonella, Shigella, and Campylobacter. ANCA and FANA were both negative. Colonoscopy revealed colitis with deep ulcers from the rectum to the midtransverse colon. Therapy with 5-ASA and prednisone was initiated and resulted in prompt disappearance of the oral and vaginal ulcers. Because of failure to wean off the prednisone, azathioprine was added. One year later, she presented with recurrent urinary tract infections and fever, but denied pneumaturia or fecaluria. Physical examination revealed multiple perirectal abscesses and fistulous tracts. An abdominal computerized tomography scan revealed air in the bladder (c, arrow) and thickened sigmoid colon adjacent to the bladder which was suspicious of a fistula. A vesiculogram showed extraluminal contrast in communication with the rectosigmoid colon compatible with enterovesical fistula. Despite maximal therapy with immunosuppressives, steroids, 5-ASA, and antibiotics, the patient required a total abdominal colectomy with ileostomy and takedown of the fistula. Microscopic examination of the colonic specimen revealed fulminant active and chronic colitis with rare granulomas consistent with Crohn’s disease (d, !900). Now, several months after surgery, the patient is doing well with no recurrence of her fistula. b

Measurement of functioning hepatocyte mass via [99mTc]galactosyl-neoglycoalbumin.

Technetium-99m-galactosyl-neoglycoalbumin (TcNGA) is a synthetic radiolabeled ligand specific for hepatic binding protein (HBP), a receptor that resides exclusively on hepatocytes.In vivo measurement of receptor concentration was obtained via kinetic analysis of liver and blood time-activity data obtained during the hepatic clearance of intravenously administered TcNGA. The purpose of this study was to assess receptor concentration as a measure of the functioning hepatocyte mass. Therefore, TcNGA and dualinjection indocyanine green maximal removal rate (ICG Rmax) studies were performed on nine patients with hepatic cirrhosis associated or not with hepatocellular carcinoma. Receptor concentration was compared with ICG Rmax, which is a validated method for the estimation of the functioning hepatocyte mass. The correlation coefficient was 0.76 (P=0.017). It is concluded that HBP concentration ([HPB]o) as measured by functional imaging is a measure of functioning hepatocyte mass. This implies that measurement of an individuals receptor concentration by using nuclear medicine techniques provides an objective index of hepatic functional mass and supports attempts to rigorously evaluate [HBP]o for its clinical efficacy.