Yang K. Chen

Successful reversal of Barrett's esophagus with multipolar electrocoagulation despite inadequate acid suppression

BACKGROUND Barretts epithelium is a risk factor for esophageal cancer. In this study we attempted to reverse Barretts epithelium in an acid-reduced environment by using multipolar electrocoagulation. METHODS All patients had specialized columnar epithelium of at least 2 cm in length. Patients with dysplasia on successive screening examinations were excluded. Esophageal motility and 24-hour pH studies were performed before therapy and at 9 and 18 weeks. All patients received lansoprazole 30 mg twice a day regardless of pH study results. Multipolar electrocoagulation was applied to one side of the esophagus (2 to 3 cm per session) with the contralateral side serving as control. Biopsies were obtained from each 2 cm length at each endoscopy and reviewed by a single, blinded pathologist. At the 9-week evaluation of the treatment side, all patients elected to undergo multipolar electrocoagulation therapy for the control side. RESULTS Twenty-seven patients completed the study: 21 men and 6 women, ages 33 to 81 years, length of specialized columnar epithelium 2 to 10 cm. Endoscopy at the 18-week follow-up showed normal mucosa (n = 16), residual small (< 3 mm) islands or tongue-shaped extensions of apparent specialized columnar epithelium (n = 7), untreated distal strips (< 5 mm) of apparent specialized columnar epithelium at the gastroesophageal junction (n = 3), and persistent specialized columnar epithelium (n = 1). Histologically, only 5 of 27 patients had residual specialized columnar epithelium at week 18. Of 16 patients with a normal endoscopic appearance, one still had specialized columnar epithelium on biopsy. While on lansoprazole, pH studies were normal in 15 of 26 patients at 9 weeks. Of 22 patients with histologic evidence of specialized columnar epithelium reversal, 10 had persistently abnormal 24-hour pH studies (pH < 4, 6.1% to 33.7% of total time). Four of five patients with residual specialized columnar epithelium on biopsy had persistent reflux. Side effects of multipolar electrocoagulation were transient, and treatment did not adversely alter motility patterns. CONCLUSIONS Multipolar electrocoagulation therapy can induce re-epithelialization with normal squamous mucosa in most patients with specialized columnar epithelium and does not adversely affect esophageal motility. Adequate acid suppression is not mandatory for therapy to be effective in the short term.

High-level disinfection of gastrointestinal endoscopes: are current guidelines adequate?

ObjectiveFor a germicide to obtain a high level disinfection (HLD) claim, FDA requires demonstration of a 6-log reduction of mycobacterial inoculum under worst case conditions. The purpose of this study was to assess the adequacy of current guidelines for high level disinfection of GI endoscopes using alkaline glutaraldehyde in simulated-use testing.MethodsVarious gastrointestinal endoscopes were contaminated with Mycobacterium chelonae in 46 experiments. Quantitative cultures were obtained from each endoscope channel separately after each step: inoculation, standardized manual cleaning, immersion in 2% glutaraldehyde (Cidex) for 10, 20, or 45 min at room temperature, 70% isopropanol rinse, and drying.ResultsManual cleaning alone achieved a 4-log reduction. After 10 min of glutaraldehyde exposure, but before alcohol rinse, two of 10 experiments failed to achieve a 6-log reduction. However, after alcohol rinse, all 10 experiments achieved HLD. After 20 min of glutaraldehyde exposure, but before alcohol rinse, one of 18 experiments failed to achieve a 6-log reduction. After alcohol rinse, all 18 experiments achieved HLD. After 45 min of glutaraldehyde exposure, but before alcohol rinse, one of 18 experiments failed to achieve a 6-log reduction. After alcohol rinse, all 18 experiments achieved HLD. Thus, if the entire reprocessing protocol including manual cleaning, glutaraldehyde exposure, alcohol rinse, and drying was taken into account, the required 6-log reduction of mycobacteria was achieved with a minimum of 10 min of glutaraldehyde exposure at room temperature.ConclusionsCurrent guidelines for high level disinfection using glutaraldehyde are appropriate. Alcohol rinse is a valuable adjunctive step for drying and for its bactericidal effects.

Percutaneous Endoscopic Gastrostomy for Nutrition Support in Pregnancy Associated With Hyperemesis Gravidarum and Anorexia Nervosa

BACKGROUND Pregnant women with hyperemesis gravidarum (HEG) or anorexia nervosa are at high risk of developing malnutrition and adverse fetal outcome. Providing adequate nutrition support is the mainstay of therapy in these patients. Because of potential complications associated with total parenteral nutrition (TPN), enteral nutrition support is the preferred route. METHODS We describe the first two reported cases of percutaneous endoscopic gastrostomy (PEG) placement in two conscious pregnant women who could not tolerate oral feedings because of severe anorexia nervosa and HEG, respectively. RESULTS PEG was placed safely and provided adequate enteral nutrition in both patients, resulting in favorable maternal and fetal outcomes. CONCLUSIONS Our observation is the first demonstration that PEG may be a safe and effective alternative to TPN in selected pregnant women with HEG or anorexia nervosa who have failed conventional treatment.

Endoscopic Management of Benign Pancreatic Disease

Since the introduction of endoscopic retrograde cholangiopancreatography (ERCP) by McCune et al. in 1968 (1) and endoscopic sphincterotomy (ES) in 1974 (2), there has been a rapid proliferation of endoscopic techniques for the diagnosis and treatment of benign and malignant biliary and pancreatic disorders. Although therapeutic ERCP has been a well-established modality for management of biliary tract disorders, its role in pancreatic diseases is still evolving (3-5). The limited number of randomized clinical trials and concern over potentially serious complications have prevented its widespread use in pancreatic disorders (6). Proper application of these therapeutic techniques and more randomized trials are needed to identify those patients with pancreatic disorders who will benefit most from endoscopic therapy. Various pancreatic disorders in which endoscopic therapy has been successfully applied are summarized in Table 1. Here we review the current status of endoscopic therapy in benign pancreatic disease.

Impact of flumazenil on recovery after outpatient endoscopy: a placebo-controlled trial

BACKGROUND Flumazenil is an imidazobenzodiazepine that blocks the central effects of benzodiazepines by competitive interaction at the receptor level. In this study we assessed the impact of flumazenil use on postsedation observation time in outpatients undergoing endoscopy. METHODS Sixty outpatients received midazolam for conscious sedation and were randomized after endoscopy to receive intravenous flumazenil (0.1 mg/mL) or placebo until awake or a total of 10 mL was given. All patients were assessed using various psychomotor and cognitive tests at baseline and at 5, 15, 30, 45 and 60 minutes after flumazenil or placebo was administered. RESULTS The two groups were similar in age, gender, midazolam dose (mg/kg), vital signs, and baseline parameters. The average dose of flumazenil given was 0.41 mg. Sedation scores returned to presedation levels earlier in the flumazenil group, with significant differences compared to placebo at 5 minutes (84.6% vs. 24.2%), 15 minutes (88. 5% vs. 57.6%) and 30 minutes (96.2% vs. 66.7%). Other parameters tested were not significantly different for patients receiving placebo compared to those given flumazenil. Sedation scores returned to baseline earlier than other psychomotor and cognitive tests in both groups. Flumazenil reduced the mean observation time from 23.5 minutes to 8.3 minutes (p < 0.0005), a difference of 15.2 minutes (64.7%) based on sedation score. CONCLUSIONS Flumazenil significantly reduces postsedation observation time. Actual cost savings will vary depending on staff and facility capacity, patient volume, flumazenil cost, and unit cost of observation time.

Addition of enemas to oral lavage preparation for colonoscopy is not necessary

To evaluate whether the addition of enemas to oral electrolyte lavage is helpful for colonoscopic preparation, we conducted a prospective, randomized, observer-blinded trial to compare oral lavage plus enemas with oral lavage alone. The quality of preparation, mucosal visualization, and the volume of retained colonic fluid did not differ between the two groups. Twenty-two percent of the patients in the group who received oral lavage plus enemas compared with 12% of the patients in the group that only received oral lavage stated that they would refuse to repeat the preparation for future colonoscopic examination. Seventeen percent of the patients in the group that received oral lavage plus enemas demonstrated anorectal trauma or inflammation compared with only 5% in the group that received oral lavage alone (p = 0.09). These results indicate that the addition of enemas to oral lavage preparation for colonoscopic evaluation cannot be routinely recommended. However, enemas may be considered on an individual basis in the occasional patient unable to consume the complete oral lavage or in whom residual stool is found during colonoscopic evaluation after oral lavage preparation.

Recent nonsteroidal anti-inflammatory drug use increases the risk of early recurrence of bleeding in patients presenting with bleeding ulcer ☆ ☆☆

BACKGROUND Nonsteroidal anti-inflammatory drug (NSAID) use is a well-known risk factor for ulcer formation and ulcer complications. The purpose of this study was to determine whether recent NSAID use increases the risk of early recurrence of bleeding in patients who present with bleeding ulcer. METHODS Clinical and endoscopic data were collected prospectively. Dose, frequency, and duration of recent NSAID use were quantified. Recent NSAID use was defined as consumption of over-the-counter or prescription NSAIDs or aspirin for at least 5 days of the 2-week period preceding the index episode of bleeding. Endoscopy was performed within 24 hours of admission to confirm the source of bleeding and endoscopic intervention was applied for stigmata of bleeding. Early recurrence of bleeding was defined as melena, hematochezia or blood per nasogastric tube with a 2 gm or greater decrease in hemoglobin during a period of 48 hours, occurring less than 2 weeks from index episode of bleeding. RESULTS One hundred twenty patients (52 NSAID users and 68 nonusers) were enrolled in the study; mean age was 56 years. NSAID users were older than nonusers (p = 0.003); nonusers were more likely to have a history of ulcer disease (p < 0.0005) and higher prevalence of Helicobacter pylori infection (p = 0.05). Recent NSAID use was associated with a significantly higher frequency of early recurrence of bleeding and in-hospital recurrent bleeding compared with nonusers: 19% vs. 6%, p = 0.02, and 17% vs. 6%, p = 0.04, respectively. In multivariate logistic regression analysis, the significant association between recent NSAID use and early recurrence of bleeding persisted (p = 0.0048) while controlling for age and other covariates. CONCLUSIONS Recent NSAID use predisposes bleeding ulcer patients to early and in-hospital recurrent bleeding, probably via its effects on platelet function, mucosal prostaglandins, and ulcer healing.

Giant duodenal ulcer. Evaluation of basal acid output, nonsteroidal antiinflammatory drug use, and ulcer complications.

Patients with giant duodenal ulcer (>2 cm) have more ulcer complications (ie, bleeding) than patients with duodenal ulcer in the standard range (0.5–1.5 cm). To evaluate possible differences between patients with giant duodenal ulcer and those with duodenal ulcer in the standard range, we determined basal acid outputs by nasogastric suction, percentage of patients with daily nonsteroidal antiinflammatory drug (NSAID) use, and percentage of ulcer complications in 184 patients with endoscopically documented active duodenal ulcer. Seventeen patients had giant duodenal ulcer, and 167 patients had duodenal ulcer in the standard range. The mean basal acid outputs for the 17 patients with giant duodenal ulcer was 7.9 meq/hr (range 0.0–27.8 meq/hr) and for the 167 patients with duodenal ulcer in the standard range was 9.0 meq/hr (range 0.0–49.1 meq/hr), which were not significantly different. There was a significant difference in the percentages of ulcer complications between the 17 patients with giant duodenal ulcer and the 167 patients with duodenal ulcer in the standard range: 65% compared to 25% (P=0.001), and in the percentages of patients with regular daily NSAID use, during the one month preceding the upper gastrointestinal endoscopy: 53% compared to 8% (P=0.00001). However, a significant association between NSAID use and duodenal ulcer complication was not apparent. These results suggest that the development of giant duodenal ulcer and the significant increase in complications associated with giant duodenal ulcer are not attributable to increased basal acid output, however, they may be attributable to increased NSAID use.

Comparison of two rapid urease tests for the detection of Helicobacter pylori infection

Rapid urease tests are widely used at endoscopyto determine the presence of Helicobacter pyloriinfection. In this prospective study, we compared theaccuracy of two rapid urease tests, CLOtest andPyloriTek, using histology as the gold standard.Histologic staining was performed using both HE their mean age was 59 years(range 16 to 95 years), and there were 45 males and 57females. Histology confirmed the presence of H. pylori infection in 39% of patients. Theproportions of false positives for CLOtest (8.0%) andPyloriTek measured at 1 hr (29.0%) were significantlydifferent (Z = 2.90, P = 0.0038). No significantdifference was seen between the proportions of falsenegatives. We conclude that the clinical usefulness ofPyloriTek urease test is limited by its lack ofspecificity.