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Background: It has been reported that the occurrence of acute cholangitis is common, especially when the self-expanding metal stent (SEMS) is placed across the main duodenal papilla., Objective: To determine the incidence of duodenobiliary reflux and acute cholangitis after placement of SEMSs across the main duodenal papilla., Design: A prospective study., Setting: A tertiary-care teaching hospital., Patients: One hundred consecutive patients with malignant bile-duct obstruction., Interventions: A barium meal examination was performed 21 days after placement of SEMSs. Reflux of barium was monitored by using fluoroscopy. The patients were also monitored for the occurrence of fever. Serum bilirubin, alanine aminotransferase, alkaline phosphatase, and total and differential leukocyte counts were evaluated before and after the barium study., Main Outcome Measurements: The occurrence of duodenobiliary reflux and acute cholangitis., Results: Two patients developed acute cholangitis because of the failure of the function of the SEMS, and they died during the first week. Severe reflux of barium was evident in all the patients. However, none of them developed features of acute cholangitis because of reflux. After a mean (SD) follow-up of 6.4 +/- 1 months, 6 patients developed acute cholangitis because of blockage of the SEMS from ingrowth of tumor or collection of debris at the lower end of the SEMS., Limitations: Unblinded study., Conclusions: After placement of SEMSs across the main duodenal papilla, reflux of duodenal contents is a universal phenomenon. Acute cholangitis was observed only in cases with blockage of the SEMS from tumor ingrowth or debris.

Background: Intramucosal incision technique is a useful procedure to achieve ductal access in patients undergoing ERCP. However, the procedure has been underused., Objective: Our purpose was to evaluate the efficacy and safety of the intramucosal incision technique and to compare it with standard precut needle-knife papillotomy., Setting: A large teaching hospital., Patients: Patients undergoing endoscopic sphincterotomy., Interventions: If a complete or an incomplete false tract formed during probing for the biliary ductal system, the intramucosal incision technique was attempted. Needle-knife precut papillotomy was performed in those in whom bile duct access could not be obtained even after 4 attempts at cannulating the bile duct., Main Outcome Measurements: The success rate and complications of the intramucosal incision technique were compared with those for kneedle-knife papillotomy., Results: The intramucosal incision technique was attempted in 23 patients and was successful in 22. A definitive procedure could be performed in all 22 patients, and mild pancreatitis developed in only one of them (4.5%). During the same period, needle-knife papillotomy was attempted in 169 patients. Biliary access was gained in 159 (94%) patients. Complications occurred in 14 (8.2%) patients (mild pancreatitis in 6, moderate pancreatitis in 2, bleeding requiring endoscopic therapy in 5, and perforation in 1 patient)., Limitations: Single center study., Conclusions: Intramucosal incision technique is a very useful and safe procedure and should be performed if a false tract has formed during probing for ductal access during ERCP.

Background: The endoscopic appearance of portal hypertensive intestinal vasculopathy is well described in the stomach, the jejunum, and the colon, but there is no description of changes that occur in the ileum., Methods: The terminal ileum was intubated at colonoscopy in 44 patients with cirrhosis and portal hypertension and 46 control patients. Changes in the terminal ileum were noted. In addition, anorectal varices and colopathy were carefully noted and recorded., Results: Ileal varices and/or portal hypertensive ileopathy were present in 16 of 44 (36%) patients with cirrhosis and portal hypertension but not in any control patient ( p < 0.01). Ileal varices were present in 8 patients (18%) with cirrhosis/portal hypertension and none of the control patients ( p < 0.05). Portal hypertensive ileopathy was noted in 11 patients (25%) with cirrhosis and portal hypertension and in none of the control patients ( p < 0.05). Ileal varices had no association with any other parameter studied. However, ileopathy was observed in 9 of the 23 patients with colopathy and in only two of the 21 patients without colopathy ( p < 0.05)., Conclusions: Ileal varices and mucosal changes of portal hypertensive ileopathy occur in patients with cirrhosis and portal hypertension. In the population studied, ileopathy was significantly more common in patients who had portal hypertensive colopathy.

Background: The frequency of colonic involvement in patients with amebic liver abscess has not been studied in detail. The factors influencing colonic involvement also are unknown., Methods: Seventy-one patients with amebic liver abscess were studied. Colonoscopy was performed in all patients., Results: Abdominal pain and fever were the most common presenting manifestations. Ten patients (14%) had diarrhea at admission. Ten other patients had a history of diarrhea during the preceding 2 months. Thirty-nine (55%) patients had colonic ulcers. Colonic ulcers were present in 18 of the 20 (90%) patients with ongoing diarrhea or a history of recent diarrhea, and in 21 of 51 (41%) patients without diarrhea (p<0.001). Thirty (42%) patients had small, discrete ulcers in the cecum, the ascending colon, or the region of the hepatic flexure. Nine patients had large, multiple ulcers with surrounding inflammation. In these patients, the ulcers were present either in the left colon (n=7) or throughout the colon (n=2). The mean (standard deviation) age of patients with 5 or more ulcers was significantly greater than that of patients with fewer than 5 ulcers (49.8 [14.6] years vs. 37 [11.7] years; p<0.05). Multiple ulcers were noted in 7 of the 10 patients (70%) with diarrhea at admission and in two of the 61 patients (3%) in whom diarrhea was not a presenting symptom (p<0.001). No association was noted between the location of the abscess in the liver and the colonic lesions., Conclusions: Colonic ulcers are a common finding, occurring in more than half of patients with amebic liver abscess. They are more likely to be present if the patient has diarrhea as a presenting symptom or has had diarrhea in the recent past. Multiple, large, and left-sided ulcers are more common in elderly patients and in those in whom diarrhea is the presenting symptom. However, there is no association between the location of the abscess in the liver and colonic lesions.

To assess reliability of the endoscopic and histologic appearance of the gastric mucosa for diagnosing portal hypertension, 50 patients with portal hypertension and 1323 controls were studied. Endoscopic evidence of mild gastritis was seen more frequently in patients with portal hypertension than in the control group (42% vs. 13.1%, p less than 0.001). The mosaic sign was also seen more frequently in patients with portal hypertension compared with controls (14% vs. 0.9%, p less than 0.001). However, the mosaic sign was found to be nonspecific, and the sensitivity for diagnosis of portal hypertension was only 14%. Biopsy specimens from the stomach of all patients with portal hypertension and 100 controls with a normal endoscopic appearance revealed mucosal vascular congestion in 72% of patients with portal hypertension compared with 59% of controls (NS). There was no correlation between endoscopic and histologic evidence of congestive gastropathy. Similarly, there was no correlation between the severity of mucosal vascular congestion and the degree of inflammatory changes observed in the biopsy specimens; both in the control (r = 0.1) and in patients with portal hypertension (r = 0.14). It is concluded that endoscopic and histologic features of the gastric mucosa in patients with portal hypertension are of low sensitivity and nonspecific and cannot be used to diagnose portal hypertension.

Between 1982 and 1987, 43 patients with variceal bleeding due to extrahepatic portal obstruction were treated by repeated endoscopic injection sclerotherapy using 1% polidocanol intravariceally. This decreased rebleeding, as evidenced by a decrease in bleeding risk factor (BRF), mean transfusion requirement, and mean number of transfusions per patient per month of follow-up. Differences between pre- and postsclerotherapy parameters were significant (p less than 0.001). The varices were eradicated in 86% of patients. The mean sclerotherapy sessions required were 7.68 +/- 2.39 (SD). Complications were infrequent. Forty-three patients were followed from 5 to 68 months: cumulative survival was 97.7% and varices recurred in 16%. Sclerotherapy avoided a second operation in 21 postsurgical patients. Sclerotherapy for managing variceal bleeding due to extrahepatic portal obstruction is a reasonable alternative to surgery.