Search

Lagergren et al. performed a population-based, case-control study to investigate the possible association between gastroesophageal reflux (GER) and adenocarcinoma of the esophagus and gastric cardia. They demonstrated an odds ratio of 7.7 for esophageal adenocarcinoma in patients with GER symptoms. The frequency, severity, and duration of symptoms correlated with an increased risk of esophageal adenocarcinoma. A weaker association was noted for GER and adenocarcinoma of the gastric cardia. No association surfaced between GER and squamous cell carcinoma of the esophagus.

Adenocarcinoma of the pancreas ranks fourth as a cause of cancer death in adults in the United States and is the second most common cause of cancer deaths of all gastrointestinal-related carcinomas. It usually presents late in its course. In this article, the authors discuss the clinical features of pancreatic cancer, with emphasis on those that allow early detection of the disease. They also review diagnostic methods and preoperative and perioperative staging that allows the appropriate application of surgical and palliative therapeutic modalities. Despite the significant progress that has been made, further research studies are needed to advance the therapeutic approach to this aggressive cancer.

In a double-blind, crossover study, we determined whether microencapusulated pancreatic enzymes reduce postprandial symptoms experienced by healthy volunteers after ingestion of a high calorie, high fat meal. At 7 AM, 18 subjects ingested 185 g of cookies (1196 calories and 72 g of fat) with three pancrelipase capsules or a placebo. The severity of gastrointestinal symptoms and flatus passages were recorded for 15-17 hr, and end-alveolar samples were obtained hourly for 10 hr. Ingestion of pancreatic supplements was associated with a significant (P = 0.049) reduction in bloating over the entire recording period, and with significant reductions in bloating, gas, and fullness during the dinner to bedtime period. Pancreatic supplements had no significant effect on breath H2 or CH4 concentration. The finding that pancreatic supplements reduce postprandial symptoms in healthy subjects suggests that these supplements also might be beneficial in irritable bowel syndrome.

Objective: The aim of this study was to evaluate the effectiveness and safety of combined hormonal therapy in patients with recurring occult gastrointestinal bleeding of obscure origin., Methods: This was a prospective longitudinal observational study. The setting was an outpatient private practice affiliated with a large university-based hospital. A total of 43 patients, comprising 14 men and 29 women with a mean age of 74 yr (range 48-86 yr), were included. They had a history of recurrent gastrointestinal bleeding of unknown origin for a period of > 1 yr and had required multiple hospitalizations and transfusions. Patients were initially treated with one Enovid 5-mg tablet containing 5 mg norethynodrel and 75 microg of mestranol. Enovid became commercially unavailable and treatment was changed to Ortho-Novum 1/50, containing 1 mg norethindrone and 0.05 milligrams of mestranol, given one tablet b.i.d. Patients were treated and followed for a mean time of 535 days (range 25-1551 days). All patients acted as their own controls and were followed for compliant behavior with periodic hematocrit, serial stool hemoccults, medication counts, and clinical histories regarding transfusion requirements or hospitalization for bleeding or anemia., Results: Of 43 patients who initially entered the study, 38 were treated with combination hormonal therapy. The remaining five patients were treated with estrogen alone. In 25 patients, initial enteroscopy revealed AVMs in the stomach or proximal small bowel and these were cauterized. In the remaining 18 patients no source of bleeding was found. None of the 38 patients who were treated with combination hormonal therapy rebled as long as they continued their prescribed dosage. All five of the patients treated with estrogen alone had rebleeding episodes. There was no statistical difference with respect to AVM cauterization in the rebleeding rate between those patients who underwent cauterization of their AVMs and those who did not. Side effects of combination hormonal therapy occurred in 11 patients and all were considered to be mild. Seven of these 11 patients (64%) elected to continue treatment., Conclusion: In this long-term observational study, combination hormonal therapy was shown to stop rebleeding in patients with occult gastrointestinal bleeding of obscure origin.

Background: Diverticular disease of the colon and its complications are well known and readily considered when patients present with the proper clinical scenario. Conversely, complications of small bowel diverticula are very uncommon entities and are not often thought of as a cause of bleeding, obstruction, or an acute abdomen., Objective: To report two patients presenting with an acute abdomen caused by acute jejunal diverticulitis who were treated nonsurgically as opposed to surgically as the literature dictates., Methods: Two patients presented with sudden onset of acute periumbilical pain that had increased progressively over 1-2 days before admission. An emergent CT scan performed in each patient with localized peritonitis revealed "collections" consistent with abscess cavities. One patient was treated with antibiotics alone and the other with a combination of antibiotics and percutaneous CT-guided aspiration. CT-guided needle aspiration was performed and the injection of contrast clearly revealed communication with a jejunal diverticulum. Both patients did well and were subsequently discharged without incident or surgical intervention., Conclusions: Acute jejunal diverticulitis must be considered in the differential diagnosis of an acute abdominal process and may be successfully treated nonsurgically despite the recommendations of previous reports.

Background: Advanced age with its concomitant comorbid conditions may be associated with increased postoperative laparoscsopic cholecystectomy (LC) complications and more frequent conversion to open cholecystectomy (OC). The purpose of this study was to evaluate the outcome of LC in patients age 65 and older., Methods: Ninety consecutive patients were studied age 65 and older, of whom 39 (43%) were males and 51 (57%) were females, mean age 74 years (range 65-98), with 20 patients (22%) >/= 80. Indications for surgery included biliary colic 55 (61%), acute cholecystitis 22 (24%), pancreatitis 10 (11%), and cholangitis 3 (4%). Seventeen patients (19%) had preoperative ERCP, 12 of which were normal; five had sphincterotomy with stone extraction. Comorbid conditions included hypertension (44%), CAD (17%), cardiac arrhythmias (18), CHF (9%), and COPD (7%)., Results: Operative time-mean 1 h 51 min +/- SD 43 min. Conversion to OC-three patients (3%). Length of stay-mean 5 days (range 1-26). Mortality-two patients (2%) >80 years old, one patient with septicemia and multiorgan failure whose comorbid diseases included CAD, C.F., COPPED, and elevated BP, one patient with MI postsurgery, morbid diseases included DM and CAD. Complications-five patients (5%): bile leak from cystic duct stump (one), postsurgery MI (two), incarcerated incisional hernia (one), septicemia (one)., Conclusion: Morbidity rates for LC in the elderly population are not different from that reported for patients less than 65 years of age. (5% vs 6%, Fried et al., Surg Clin North Am 1994;74 [2]: 375-387). Our 2% mortality rate is statistically different from previously reported in a series of patients of all ages (0.6%, Fried et al.). The 3% rate of conversion to OC in this older population is not significantly different from the patients in Fried et al. series (4%).

Secondary pancreatic tumors should be considered in those patients who present with a solitary pancreatic mass and who have had a previous nonpancreatic malignancy. The most common primary tumor origin of solitary pancreatic metastases is renal cell carcinoma, but many other primary sites have been reported. Radiological studies are useful for determining size and resectability, but a biopsy for tissue confirmation is required to differentiate primary and secondary pancreatic tumors. Survival data from patients who had solitary metastasis to other organ sites suggest that an aggressive surgical approach may improve survival. Characteristics of the primary tumor including tumor grade and histology may also affect prognosis. Prospective studies evaluating survival after surgical therapy have not been undertaken.

Occult gastrointestinal bleeding is most commonly defined as an acute or chronic loss of blood, the source of which has not been identified after gastroscopy, colonoscopy, and upper gastrointestinal series have been performed. As the title suggests, this article provides a general overview of this disorder. Specific topics discussed include etiology, diagnostic procedures, laboratory studies, radiologic procedures, radionuclide studies, angiography, and endoscopy.

Pancreatic necrosis as a consequence of acute pancreatitis usually implies a poor prognosis. Infection is the most common complication affecting mortality and appears to be increasing. While bacterial infections, particularly with coliforms, account for the majority of cases of infected necrosis, fungal infections are being more frequently documented. This may be due to increased recognition through improved laboratory techniques, more aggressive diagnosis by percutaneous aspiration, or the more widespread use of broad-spectrum antibiotics or parenteral nutrition. While the majority of documented fungal pancreatic infections have been with Candida species, recent reports have highlighted the importance of Torulopsis glabrata. This haploid yeast of the family Cryptococcaceae is a fungal commensal organism accounting for 16% of all human yeast isolates. Here we report the first case of T. glabrata infection complicating pancreatic necrosis and review the current knowledge of pancreatic fungal infections complicating acute pancreatitis. Superimposed infection, either bacterial or fungal, needs to be diligently sought in patients with pancreatic necrosis who fail to improve or deteriorate despite supportive care.

Objective: We sought to determine the incidence and outcome with conservative management of esophageal nontransmural tears after pneumatic dilation for achalasia., Methods: Retrospective review of 50 pneumatic balloon dilations in 30 patients with achalasia was performed at one center over an 18-month period., Results: Forty-four of 50 procedures (88%) were performed without complication. Two patients (4%) developed transmural perforations requiring immediate surgical repair; both recovered uneventfully. Four patients (8%) were found to have linear mucosal tears on routine postprocedure esophagrams. One patient was asymptomatic, and three had chest pain. No patient had fever. These four patients were managed conservatively with in-hospital observation for a mean of 4.3 days (range 3-6): nothing by mouth for a mean of 1.3 days (range 1-2) and i.v. antibiotics for a mean of 3 days (range 2-5). All were discharged within 6 days and were asymptomatic and tolerating a regular diet., Conclusions: Esophageal nontransmural tears are not uncommon after pneumatic dilation for achalasia and can be safely treated with conservative medical management.

Endoscopic biopsy forceps vary in size and design. The purpose of this prospective randomized study was to compare the quality and quantity of gastric tissue obtained by needle and non-needle versions of standard biopsy forceps and newly designed large capacity forceps. Fifty consecutive patients who underwent endoscopy with gastric biopsy forceps were enrolled in the study. There was no significant difference in the presence of crush artifact between the two forceps, both with and without the presence of a needle. Both needle and non-needle versions of the large capacity biopsy forceps were found to obtain significantly larger sized specimens (p = 0.02) than needle and non-needle versions of the standard biopsy forceps. Overall, there was no significant difference in the depth of specimen obtained when comparing the large capacity forceps to standard forceps. Needle versions of each forceps were found to obtain significantly deeper biopsies than non-needle versions of each forceps. In conclusion, our study found that large capacity forceps obtained larger specimens than standard biopsy forceps. Further clinical trials with a larger study population need to be undertaken to determine the impact of these findings on the determination of diagnoses.

Objectives: Endoscopic investigation of the small intestine remains the last frontier for gastroendoscopists. We evaluated the diagnostic efficacy and safety of two different push-type, fiberoptic enteroscopes in the investigation of patients with occult gastrointestinal bleeding or suspected small bowel pathology., Methods: Sixty-six patients (28 men, 38 women; mean age, 68) underwent push-type enteroscopy with either the SIF 10.5L (n = 17; scope length, 2495 mm) or the SIF 3000 (n = 49; length, 2995 mm) enteroscopes (Olympus America, Inc., Lake Success, New York). All patients enrolled had an indication of either occult gastrointestinal bleeding (n = 55) or suspected small bowel pathology (n = 11). Push-type enteroscopy was performed with an overtube and fluoroscopic guidance to better estimate the degree of insertion. Assessments of mucosal visualization, tip deflection, procedure tolerance, and complications were noted., Results: Visualization of the small bowel mucosa and tip deflection was rated excellent in all patients. The mean length of insertion past the ligament of Treitz for the SIF 10.5L was 90 cm and 113 cm for the SIF 3000. Only one complication, a pharyngeal tear, occurred with the SIF 3000. Lesions that may explain the occult GI bleeding were found in 35 out of 55 patients (64%). Twenty-one of these 35 patients (60%) had lesions proximal to the ligament of Treitz, and 14 patients (40%) had lesions distal to the ligament of Treitz. If only distal lesions were considered, the diagnostic yield was 25% (14/55) for occult GI bleeding and 73% (8/11) for suspected small bowel pathology. The most common lesions were arteriovenous malformations (34%), which were successfully cauterized., Conclusion: With a relatively high diagnostic yield and therapeutic capability, push-type enteroscopy should play an important role in the investigation and treatment of lesions causing occult GI bleeding and small bowel pathology.

Objectives: The purpose of this prospective study was to determine if medical and nursing staff in the United States who are regularly involved in endoscopic procedures are at an increased risk of acquiring Helicobacter pylori infection., Methods: One hundred and twenty-two gastroendoscopists and endoscopy nurses attending an advanced gastroendoscopy course (17 women, 105 men) completed a questionnaire consisting of past medical and professional history. Serum from each subject was collected and tested using a validated ELISA assay (sensitivity 99%, specificity 96%). H. pylori prevalence in the experimental group was compared to that of 510 blood donors., Results: In all age groups, H. pylori positivity was significantly higher among the study subjects compared with controls. Caucasian subjects, when matched to controls for age, race, and level of education, had significantly higher rates of H. pylori positivity. Foreign-born subjects, when compared to US-born subjects, also had higher rates of H. pylori positivity. There was no statistical difference of H. pylori positivity with respect to gender, years involved in endoscopy, or number of endoscopies performed monthly., Conclusion: H. pylori infection is more common in gastroendoscopists and endoscopy nurses than the general population and should be viewed as an occupational hazard.

Chronic pancreatitis is uncommon in children and adolescents. A rare syndrome of idiopathic fibrosing pancreatitis has been reported in 28 patients, ages 4 months to 17 yr. We report two young adults with this syndrome who presented with obstructive jaundice. Both were seen in adult gastroenterology practice, and one is the oldest reported patient at age 20. We review the clinical features, diagnosis, and treatment of this disorder, which merits attention by adult gastroenterologists.

A leading cause of biliary tract disease and pancreatitis worldwide is parasitic disease. In the United States, increased global travel and the AIDS epidemic has led to a rise in the frequency of parasitic disease. Biliary disease and pancreatic disease secondary to parasitic infestation is relatively new in this country, with the first case being described in 1977. These diseases are no longer the exclusive realm of infectious disease specialists and require general practitioners and gastroenterologists to be well versed in the spectrum of parasitic pancreatic and biliary disease.

Somatostatin and its analogue (SMS 201-995, octreotide) have proven to effectively inhibit various gastrointestinal functions including exocrine and neuroendocrine secretion, motility and splanchnic blood flow. The long half-life and the ability to administer the analogue subcutaneously has liberalized its use in different intestinal and extraintestinal disorders. In particular, the profound inhibitory effects on exocrine pancreatic function have prompted the use of SMS in several pancreatic disorders. Despite the lack of controlled studies, somatostatin has been used in different pancreatic disorders, fistulas, pseudocysts and ascites. The preliminary evidence supports a definite role of this analogue as adjunctive and primary therapeutic agents.

We describe the case of a 41-yr-old man who presented with signs and symptoms of cholestasis including abdominal pain, jaundice, and fever, with peripheral eosinophilia of 10% and bone marrow eosinophilia. Liver biopsy revealed an eosinophilic infiltrate and an ERCP demonstrated bile duct changes, compatible with primary sclerosing cholangitis (PSC). After treatment with prednisone and ursodeoxycholic acid, the patient's liver profile tests returned to normal, the ERCP changes resolved, and all symptoms disappeared. A literature review has not shown any previous reports of reversible sclerosing cholangitis, secondary to eosinophilic infiltration. The purpose of this report is to describe eosinophilic cholangitis, an entity that mimics PSC in the context of the hypereosinophilic syndrome.

We report a patient who developed pancreatic pseudocysts involving both hepatic lobes, after an episode of alcoholic pancreatitis. The possible routes by which pancreatic secretions may reach the liver, as well as diagnostic and therapeutic approaches, are discussed.

Acute pancreatitis is an inflammatory disease of variable clinical severity. The pathologic conditions that correlate with clinical severity and with local systemic complications range from mild edema to pancreatic an peripancreatic necrosis. This article discusses diagnosis, etiology, laboratory evaluation, and imaging studies with respect to acute pancreatitis. Assessing the prognosis, detecting complications, and therapy are discussed also.