Search

Gastric polyps are rare and largely asymptomatic, but attract importance because of their strong potential to progress to carcinoma. Rarely, pedunculated polyps arising in the antrum may prolapse through the pylorus, causing intermittent gastric outlet obstruction. We describe here our experience of four cases collected over a ten-year period, each presenting dissimilarly with this phenomenon. We review the literature referring to the pathogenesis of gastric polyps and their association with malignancy and other disorders. We proceed to discuss the efficacy of barium studies versus gastroscopy in detecting these lesions, the relative roles and merits of endoscopic polypectomy and surgery, and the importance of prolonged follow-up of patients harbouring gastric polyps.

Acute pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP) occurs in 3-18% of patients undergoing either diagnostic or therapeutic ERCP. We prospectively measured urinary trypsinogen activation peptides (TAP) by an automated anti-TAP enzyme-linked immunoassay among 107 patients 4 h after ERCP to determine whether this measurement helps in the early diagnosis of ERCP-induced pancreatitis. Pancreatitis was documented in 10 of 107 patients (9.3%). All episodes were graded as mild. Urinary TAP was not significantly increased. We conclude that measurement of urinary TAP 4 h after ERCP is not helpful in documenting mild ERCP-induced acute pancreatitis.

We report three cases of pancreatic islet cell tumors causing stricture of the main pancreatic duct. The clinical presentation was consistent with episodes of acute pancreatitis or biliary colic. One patient in whom the diagnosis was delayed died of metastatic disease. Islet cell tumors are an important clinical entity that must be considered in the differential diagnosis of pancreatic duct strictures.

Endoscopic sphincterotomy has revolutionized the approach to numerous biliary and pancreatic diseases. The indications, technique, and complications of endoscopic sphincterotomy are covered in detail in this article.

An understanding of the principles and limitations of monitoring devices is valuable for their appropriate use and interpretation. Reliable monitoring de available as an adjunct to skilled personnel to detect changes in patient condition during endoscopy. Combination units that provide pulse oximetry, automated sphygmomanometry and ECG monitoring appear to be the most convenient and cost effective products.

Balloon dilation is an acceptable modality for the dilation of stenoses at various sites in the gastrointestinal tract. In the esophagus its reported efficacy and safety is similar to bougienage; in other sites it offers an alternative to surgical treatment, in most cases as the definitive therapy.

Data supporting the preferential use of disposable endoscopic accessories is limited. These devices have been widely disseminated without careful evaluation of their impact on the environment and medical costs. In addition, current facility reimbursement for endoscopic procedures does not adequately cover the costs of these accessories. Re-use of accessories labelled "for single use only" as a potential means to reduce costs has not been carefully evaluated. More prospective data comparing the efficacy, safety, and cost effectiveness of disposable versus reusable accessories is needed.

Objectives: Bile leaks are a well documented complication of biliary surgery, occurring more frequently with laparoscopic procedures. Endoscopic therapy with a long biliary endoprosthesis traversing the site of the leak is effective. We have evaluated the hypothesis that equalizing biliary and duodenal pressures with a short transpapillary stent is an equally effective therapy for bile leaks., Methods: Thirty one consecutive patients presenting over a 52-month period with postsurgical bile leaks were evaluated. Patients had been treated with long endoprostheses (stents or nasobiliary tubes), sphincterotomy, or short transpapillary stents. The success, complication rate, need for additional therapy, and hospitalization time of each therapeutic approach were determined., Results: Endoscopic therapy was successful in all 25 patients in whom a bile leak could be documented. The clinical success, need for radiological drainage, length of hospitalization, and incidence of pancreatitis were similar for all methods of treatment., Conclusions: These results confirm that endoscopic therapy is highly successful in the treatment of postoperative bile leaks and suggest that the mechanism of healing is the equalization of bile duct and duodenal pressures, allowing flow of bile into the duodenum. The endoscopic placement of short transpapillary stents without sphincterotomy is a temporary, effective, and technically simple method of pressure equalization. This should be considered as the primary therapy for most postoperative bile leaks.

Endoscopic stenting has revolutionized the palliation of malignant biliary obstruction. Individuals with biliary obstruction due to pancreatic malignancy are best managed by a team approach comprising individuals with expertise in oncology, surgery, endoscopy, and radiology. The clinical value of alleviating jaundice and associated symptoms of anorexia, pruritus, and malaise cannot be overestimated. These quality-of-life factors deserve more attention in future studies to define subgroups of patients most likely to derive benefit from the array of treatment options. Further technical improvements are required to solve the most important clinical problem of late stent occlusion. New developments such as expandable metallic stents and refinements in existing equipment and techniques have already resulted in measurable gains and hold great promise for future expansion of their use in malignant gastric outlet obstruction secondary to tumor infiltration of the duodenum. Corresponding advances are being made in the fields of percutaneous transhepatic intervention and hepatobiliary surgery such that further prospective randomized trials are necessary to define optimal therapy.

Unlabelled: Dysphagia is not always present in patients with esophageal squamous cell papilloma, and it can be an incidental finding during gastrointestinal endoscopy of an asymptomatic patient., Purpose: Three cases of squamous cell papilloma of the esophagus and aspects regarding diagnosis and association with human papillomavirus are presented. CASUISTIC: Two cases are male and one female what is consistent with a higher incidence showed in the literature in males. The three patients were submitted to upper gastrointestinal endoscopy: in one case the tumor was unusually large and in all patients it was located in the mid and lower esophagus. Chromoscopy was performed in one case and the lesion was not stained. We were unable to identify human papillomavirus using DNA-hybridization techniques. Our results are similar to those reported in the review of the literature., Results: There is no other case published in the Brazilian literature and this is the first report on the use of chromoscopy., Conclusion: We were not able to show an association between esophageal squamous papilloma and human papillomavirus.

The successes of supportive management of patients with severe acute pancreatitis in recent years has evolved from our improved understanding of some of the serious consequences of pancreatic necrosis on other organ systems. When gallstone disease is identified as the cause in such patients, there has been an expectation that biliary intervention will lead to a more rapid resolution of the index attack and prevention of future pancreatitis. There is now convincing evidence, in the setting of severe gallstone-associated pancreatitis using prognostic scoring, that not only is emergency or early elective biliary surgery associated with an unacceptable morbidity and mortality but that appropriate endoscopic therapy is safe and highly effective. In populations where concomitant cholangitis is common, emergency biliary endoscopic management provides optimal therapy for all grades of pancreatitis.

Gastric duplication cysts are rare and generally asymptomatic in adults. They are usually discovered incidentally at upper gastrointestinal endoscopy or barium contrast radiography. We report here the case of a 41-year-old woman with a gastric submucosal mass, initially diagnosed as a leiomyoma that proved to be a gastric cyst. The cyst was aspirated under direct endoscopic vision using a standard sclerotherapy needle. To our knowledge, this is the first description of such a procedure.

Seven consecutive patients presenting acutely with suspected variceal hemorrhage underwent endoscopic variceal ligation (EVL) of esophageal varices. Active bleeding had ceased by the time of the initial EVL session in all patients, although active variceal hemorrhage was controlled by EVL in one patient during a subsequent episode of bleeding. Treatment sessions were repeated at approximately monthly intervals until varices were reduced in size to grade 1 (< 4 mm diameter) or eradicated. All patients had portal hypertension secondary to intrahepatic disease. Patient age ranged from 2.4 to 14.5 years (mean, 8.5 years). One patient underwent successful liver transplantation 1 week after the initial treatment session. The remaining six patients required a mean (+/- SD) of 4.0 +/- 1.3 treatment sessions for elimination of varices. One episode of recurrent variceal hemorrhage and one episode of treatment-related hemorrhage occurred in two separate patients. Transient, mild dysphagia or odynophagia occurred in all patients. No other complications were reported during a mean (+/- SD) follow-up period of 13.8 +/- 4.6 months (range, 8-20 months). Recurrent varices were seen in three of four (75%) patients returning for follow-up endoscopy between 5 and 8 months from initial eradication. All underwent repeat EVL without complication. Endoscopic variceal ligation may be a suitable substitute for sclerotherapy in children with bleeding esophageal varices.

Mucinous pancreatic neoplasms present diagnostic and therapeutic challenges. These tumors behave in an indolent nature, with frequent overlap of symptoms and radiographic appearance with other forms of pancreatic cysts, pseudocysts, and malignancy. Some authors propose that all mucin-producing tumors of the pancreas are variants of the same basic entity and have subclassified them on the basis of their predominant location within the pancreas. These disorders must be considered in the evaluation of chronic abdominal pain, particularly in the presence of a cystic pancreatic lesion or when associated with idiopathic chronic or acute recurrent pancreatitis. The clinicopathologic features of IMHN overlap to a great extent with classic mucinous cystic neoplasms but are different significantly enough to be distinct clinical entities. These tumors originate from the pancreatic duct epithelium, produce mucin, demonstrate a papillary growth pattern, and are considered premalignant or frankly malignant at the time of diagnosis. Both lesions biologically are much less aggressive than that of pancreatic ductal adenocarcinoma and appear to infiltrate peripancreatic tissue and to metastasize to lymph nodes or other adjacent structures late in the course of disease. Nevertheless, IMHNs are located primarily in the head of the pancreas, commonly affect elderly men, and present clinically with obstructive pancreatitis, often leading to pancreatic insufficiency, whereas mucinous cystic neoplasms are more likely to develop in the pancreatic body or tail, predominate in young women, and present with symptoms referable to tumor compression of adjacent structures. The location of the lesion is the primary differentiating feature because the lining epithelium of the two tumor types is indistinguishable pathologically. In mucinous cystic tumors, the mucus is secreted and retained within the cyst lumen because of the absence of communication between the cyst and the main pancreatic duct. In contrast, mucus produced in MDE flows into the main pancreatic duct, resulting in obstructive pancreatitis and, ultimately, dilatation of the pancreatic duct. Intraductal mucus provides an important clue to the diagnosis of intraductal pancreatic neoplasms and, whenever present, should prompt an aggressive diagnostic evaluation. Both lesions are managed by resectional surgery because the opportunity for cure is high in the absence of metastatic disease.

Nitric oxide (NO) is an inhibitor of gastrointestinal smooth muscle. Model systems of the gut predict the NO will complex with biological thiol (SH) groups, yielding S-nitrosothiols (RS-NO), which may limit the propensity to form mutagenic nitrosamines. The inhibitory effects of NO and its biologically relevant adducts on sphincter of Oddi (SO) motility have been inferred from animal studies; however, their importance in regulating human SO is not known. The objectives of this study were to (a) provide histologic confirmation of nitric oxide synthase (NOS) in human SO; (b) characterize the pharmacology of S-nitroso-N-acetylcysteine (SNAC), an exemplary S-nitrosothiol, on SO motility in a rabbit model; and (c) study the effects of topical SNAC on SO motility in humans. Immunocytochemical and histochemical identification of NOS was performed in human SO. The pharmacologic response of SNAC was defined in isolated rabbit SO using a standard bioassay. Topical SNAC was then applied to the duodenal papilla in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and biliary manometry. NOS was localized to nerve fibers and bundles of the SO in rabbits and humans. SNAC inhibited spontaneous motility (frequency and amplitude) as well as acetylcholine-induced elevations in SO basal pressure in the rabbit model. In patients undergoing ERCP and biliary manometry, topical SNAC inhibited SO contraction freqency, basal pressure, and duodenal motility. NOS is localized to neural elements in human SO, implicating a role for NO in regulating SO function. Supporting this concept, SNAC is an inhibitor of SO and duodenal motility when applied topically to humans during ERCP. Our data suggest a novel clinical approach using local NO donors to control gastrointestinal motility and regulate sphincteric function.

Objective: The objective of this report was to determine the clinical outcome of intervention among patients with a pancreatic pseudocyst associated with sterile pancreatic necrosis., Methods: We reviewed records of all patients with sterile pancreatic necrosis who required intervention during the past 10 yr., Results: A total of 17 patients required intervention. Twelve with sterile necrosis unassociated with a pancreatic pseudocyst underwent surgical debridement. An additional five patients with sterile necrosis associated with a pancreatic pseudocyst underwent drainage of the pseudocyst (two by pigtail catheter drainage, one by endoscopic cyst gastrostomy, and two by surgical cyst gastrostomy). After drainage, four of these five patients developed pancreatic infection that required surgical debridement. Pancreatic infection occurred because the drainage procedures in these four patients failed to remove the underlying necrotic material., Conclusions: When a pancreatic pseudocyst occurs in association with pancreatic necrosis, radiological and endoscopic decompression should not be attempted.

Endoscopic retrograde cholangiopancreatography is a valuable tool in the diagnosis and management of pancreaticobiliary diseases. The diagnostic sensitivity of brush cytology is reported as between 18% and 70% for malignant bile duct or pancreatic duct strictures. We report our findings in 74 patients with pancreaticobiliary strictures who underwent ERCP. Brush cytology was performed on 55 bile duct specimens and 19 pancreatic duct specimens. No complications related to the procedure occurred; 4 specimens (5.4%) were unsatisfactory for interpretation. Strictures were benign in 22 patients (12 pancreatitis, 5 sclerosing cholangitis, 3 Mirizzi syndrome, and 2 papillitis) and malignant in 52 patients (29 pancreatic carcinoma, 10 cholangiocarcinoma, 6 metastatic disease, 4 pancreatic mucinous ductal ectasia, 1 ampullary carcinoma, and 2 non-functioning islet cell tumors). The nature of the stricture was confirmed by surgery, surgical biopsy, necropsy, or follow-up. The overall results for brush cytology were sensitivity 56.2%, specificity 100%, positive predictive value 100%, negative predictive value 51.2%, and accuracy 70%. Our results confirm the value, safety, and utility of obtaining cytologic specimens at the time of ERCP; confirmation was obtained in 65.5% of pancreatic carcinoma cases. Although a negative result does not exclude pancreaticobiliary malignancy, a positive result confirms this diagnosis.

Pathophysiology of the sphincter of Oddi--or sphincter of Oddi dysfunction--manifests as either a biliary-type pain syndrome or recurrent pancreatitis. Imaging studies are unreliable, and direct endoscopic manometry is used to diagnose this entity. Milwaukee biliary classification, in addition to manometry, helps guide therapy. Endoscopic sphincterotomy in selected patients achieves permanent relief of symptoms. Endoscopic therapy for recurrent pancreatitis is still experimental.

Endoscopic sclerotherapy of esophageal varices rapidly became the standard initial nonsurgical method for control of hemorrhage. Although in widespread use around the world, the technique is associated with a significant complication rate that excludes it as a potential method for primary prophylaxis. The sclerotherapy technique has been difficult to standardize between different endoscopists and centers, with consequent incongruities in trial results and morbidity. The introduction of endoscopic band ligation heralds the possibility of a simple, reproducible method for acute and chronic treatment of varices and the hope that prophylactic eradication, before the first life-threatening hemorrhage, can be achieved safely and effectively.

In a series of 650 consecutive laparoscopic cholecystectomies, nine bile leaks were identified (1.4%). Patients with bile leaks presented clinically at a mean of 4.9 days (range: 3-8 days) after surgery complaining of diffuse abdominal pain, ileus, and nausea. Laboratory values for complete blood counts and liver function tests were all mildly elevated. Definitive diagnosis was made on the basis of abnormal hepatobiliary scintigraphy. Management strategies included laparotomy and drain placement (n = 1), laparoscopy and drain placement (n = 3), ERCP and drainage (n = 4), and CT-guided percutaneous drainage (n = 1). When the etiology of the leakage was identified, it was most commonly either dysfunction of the cystic duct clips (n = 3) or leakage from a disrupted duct of Luschka (n = 2). The source of the remaining leaks (n = 4) was never determined. We conclude that bile leaks are an uncommon cause of morbidity following laparoscopic cholecystectomy. Diagnosis can usually be made with nuclear medicine biliary tract scans and a variety of managements alternatives are successful in treating this complication.

The role of intraoperative cholangiography during laparoscopic cholecystectomy was prospectively evaluated in 514 patients undergoing laparoscopic cholecystectomy. Before surgery, all patients were assigned to one of three groups depending on the likelihood of their having common bile duct stones. Stratification was based on objective historical, laboratory, or radiologic criteria. In 453 patients deemed unlikely to have stones, laparoscopic cholecystectomy was performed without cholangiography. Of these patients, four had retained stones (0.9%). In 25 patients likely to have stones, preoperative endoscopic retrograde cholangiopancreatography identified stones in six patients (24%). In 36 patients whose likelihood of having stones was deemed indeterminate, intraoperative cholangiography was performed at laparoscopic cholecystectomy. A common bile duct stone was identified in one patient (2.8%). One common bile duct injury occurred in the group deemed unlikely to have stones, and this injury would not have been prevented by intraoperative cholangiography. We conclude that preoperative assessment will identify common bile duct stones and that routine cholangiography is not warranted. Meticulous dissection of the cystic duct at its origin at the infundibulum will prevent common bile duct injury.

Failure of extracorporeal shockwave lithotripsy is most frequently related to total stone mass, the size of individual stones, or unrecognized stone calcification which interferes with the dissolution effects of orally administered bile salts. We report a case of piezoelectric extracorporeal shockwave lithotripsy failure in a young woman with a 2-cm stone impacted in the neck of the gallbladder. Despite adequate positioning of the shockwave focal point on two separate occasions, no fragmentation was achieved. The stone was subsequently retrieved after the woman underwent laparoscopic cholecystectomy. When treated ex vivo, the stone rapidly fragmented. We hypothesize that the impacted stone, lacking a uniform liquid interface, failed to fragment because of the inability of cavitational forces to achieve a surface effect.

Early identification of those patients presenting with acute pancreatitis due to gallstone disease is important since emergency intervention may prevent the development of local and systemic complications. Urgent biliary surgery carries unacceptably high morbidity and mortality rates, but endoscopic retrograde cholangiopancreatography in experienced centers appears to be safe and is the optimal method for the diagnosis of bile duct stones. Two randomized controlled prospective trials have shown an advantage for endoscopic sphincterotomy and bile duct clearance compared with supportive therapy when performed within 24 to 72 hours of admission in those patients whose symptoms are considered severe according to prognostic scoring systems.

The integrity of the main pancreatic duct (MPD) was evaluated by endoscopic retrograde pancreatography (ERP) in a retrospective study of 105 patients with acute pancreatitis presenting over an 11-year period (1980-1991). The findings were compared with clinical outcome and the need to operate for local pancreatic complications. Patients were divided into two groups. Group 1 (n = 89) had either clinically mild pancreatitis or severe disease but no surgery for local complications, and < 25 per cent necrosis on contrast-enhanced computed tomography (CT) (n = 48). Group 2 patients (n = 16) had clinically severe pancreatitis and underwent surgery for local complications and/or had > or = 25 per cent necrosis on CT (n = 12), at surgery or post mortem. All 89 patients in group 1 had an intact MPD at ERP, which was performed a median of 6 (range 0-30) days after onset of pancreatitis; the median age was 63 (range 20-88) years and there were no deaths. The median age of patients in group 2 was 59 (range 26-85) years. ERP in this group was performed in four patients < 5 days after onset and all had an intact MPD; one died with necrosis and another from a cerebrovascular accident. ERP was performed > or = 5 days after onset in the other 12 patients; five had an intact MPD and two required surgery for pseudocyst drainage only; seven had a disrupted MPD and all required surgery for pancreatic necrosis (one death). It is concluded that an intact MPD was a feature of mild pancreatitis, whereas disruption occurred > 4 days after onset in patients with necrosis necessitating surgery.

A retrospective, epidemiological study of abdominal tuberculosis in the city of Leicester from 1972 to 1989 is reported. Potential cases were identified from hospital medical records and endoscopy lists, in addition to the county notification register. The city population of 280,000 included over 75,000 South Asians. There were 146 cases among South Asians and six in Europeans, four of whom were British. The standardised incidence of abdominal tuberculosis in South Asians decreased significantly from 22.3 cases/10(5)/year during the 1970s to 9.2 cases/10(5)/year in the 1980s (chi 2 = 42, p < 0.001). The incidence during the 1980s was 10.7/10(5)/year in Hindus, 8.7/10(5)/year in Sikhs, and 4.6/10(5)/year in Muslims. The relative risk to Hindus was 2.3 fold greater, and for Sikhs 1.9 fold greater, than that for Muslims, a finding similar to that in pulmonary tuberculosis. The standardised incidence in Europeans was 0.2/10(5)/year and they had significantly less abdominal tuberculosis than South Asians (Z = 8.6, p < 0.001 and relative risk = 46). The standardised mortality ratio was significantly increased in Europeans (standardised mortality ratio = 755, 95% confidence interval 90-2730, chi 2 = 11.4, p < 0.001), but not in South Asians (standardised mortality ratio = 68, 95% confidence interval 20-160). Resection rates were similar between the two ethnic groups. Abdominal tuberculosis still occurs among migrants, and clinicians should remain alert to this in South Asians.

Speech recognition technology has developed substantially in the past half decade. Currently, large vocabulary, speaker independent, discrete recognizers are the state-of-the-art. This will change. Moderate sized, continuous recognition systems now exist in research settings. However, it is unlikely that such systems will be widely available until the mid to late 1990's. The accuracy rates of current speech recognition systems are high. Consequently, speech accuracy is not the current limiting aspect of using ASR. The limiting aspect of using ASR technology is the approach to integrating speech functionality into applications. One approach is to use ATNs as models of natural language to support both an input strategy and a text generation system. ATNs provide approaches to both syntactical correctness and semantic richness. This is an approach which plays to the strengths of the discrete nature of current speech technology and also provides a methodology for the capture and archiving of highly detailed information. The ATN approach avoids the natural language parsing problem created by a fully free form dictation interface. Evolving along with the underlying speech technology are standards in the definitions and criteria used in endoscopic practice. There are clear benefits from standards in this area. However, it is likely that this will also take several years and may never yield a universally accepted lexicon. Furthermore, there will be user interface barriers to surmount in any system attempting to use speech as an input modality. Because of the relatively large vocabularies used in medical discourse, the user interface will need to be carefully crafted.(ABSTRACT TRUNCATED AT 250 WORDS)

The main limitation in the endoscopic palliation of malignant biliary obstruction is due to stent blockage. One of the factors thought to be of importance is the diameter of the endoprosthesis. In this paper, we report the results of a multicenter European study with a one cm diameter self-expanding metal stent (Wallstent) in 103 patients with malignant biliary obstruction. Insertion of the stent following guidewire positioning was successful in 97.1% of the patients without any cases of de novo cholangitis developing after the endoscopic procedure. The median follow-up for the entire group was 145 days. In all but 3 patients, the stent expanded to more than 80% of its maximum diameter. Two patients had ongoing cholangitis after stent insertion. Long-term complications manifested by late cholangitis, were seen in 18% of the cases after a median interval of 125 days. The occlusion rate by biliary sludge was 5% after a median time period of 175 days which is substantially less than the 21% occlusion rate reported for polyethylene stents. In conclusion, our results show that the Wallstent can be easily placed in distal and mid-CBD strictures after guidewire passage, with most of the patients having a- good drainage effect. The occlusion rate by biliary sludge is significantly less than for conventional polyethylene stents, but the occlusion by tumor ingrowth is substantial. A disadvantage is the high cost of the Wallstent. Further randomized trials will be required to determine the cost-benefit ratio for the use of this stent.

In a 6-month period, 17 consecutive unselected patients undergoing emergency or elective endoscopic variceal band ligation were evaluated prospectively for clinical and bacteriological signs of bacteremia after each treatment session. None had signs of sepsis, fever, or chills; however, in one patient, a coagulase-negative Staphylococcus epidermidis was cultured from peripheral blood at 5 but not 30 min after the procedure. These data indicate that, in contrast to sclerotherapy, endoscopic variceal ligation rarely induces bacteremia.

The irritable bowel syndrome (IBS) is a common disorder estimated to affect up to 20% of adult Caucasians, with only a small percentage requiring investigation. This prospective study was performed to substantiate the impression that patients with IBS experience more pain during endoscopic examination of the colon than do patients with other conditions. Patients with IBS were observed to experience significantly more pain during colonoscopy than did patients without IBS (median observed pain scores 46 and 9, respectively), p < 0.001. The intensity of the pain perceived during examination was significantly higher for patients with IBS than for those without IBS (median 52.5 and 23.5, respectively), p < 0.001. Within the groups, there was no significant difference between flexible sigmoidoscopy and colonoscopy in observed or perceived pain. 64% of the patients with IBS said that the pain experienced at colonoscopy was identical to their presenting pain. This study supports the hypothesis of a lower colonic pain threshold with colonic hyperalgesia in patients with IBS. We have found that hypersensitivity to the endoscopic examination of the colon is a useful clinical adjunct in the diagnosis of the IBS in those selected to undergo colonoscopy.

An endoscopic band ligation method was successful in achieving hemostasis in two patients who had severe coagulopathy and profuse gastrointestinal bleeding from a visible vessel in the stomach. Bleeding was not controlled by multiple epinephrine injections or BICAP electrocoagulation. The technique of band ligation was easy to perform and may provide an alternative treatment for non-variceal upper gastrointestinal bleeding in selected cases.

A 60-year-old male presented with findings on radiographic and physical examination which were compatible with colonic obstruction. A tube cecostomy was performed. Colonoscopy seven months later revealed a pseudotumor composed of granulation tissue in the cecum at the site of the previous cecostomy.

Endoscopic retrograde cholangiopancreatography (ERCP) findings in 405 patients were analyzed to compare common bile duct (CBD) and main pancreatic duct (PD) diameters in relation to age, sex, gallbladder stones, CBD stones and acute pancreatitis. There were 129 patients with gallstones uncomplicated by pancreatitis, 131 patients with pancreatitis, and 145 control subjects. Significant correlations were found between CBD and PD diameters, and between these and age. Independently significant determinants of the CBD diameter were age, female, sex, CBD stones and gallbladder stones, as well as PD diameter. Conversely, PD diameter was significantly dependent upon age, CBD diameter, and acute pancreatitis. This study suggests that both CBD and PD dilation occurs in patients with gallstone disease. In view of the different factors which affect CBD and PD diameters (particularly age), important clinical decisions previously recommended on the basis of these duct diameters may need to be qualified.

Laparoscopic cholecystectomy has emerged in the last 2 years as a unique procedure that offers the long-term advantages of open cholecystectomy without much of the short-term morbidity. Importantly, when compared with non-surgical approaches to symptomatic gallstones, it is suitable for virtually all patients rather than a highly-selected group as in the case of oral bile salt dissolution therapy or extracorporeal lithotripsy. Furthermore, it obviates the high recurrence rate seen with these techniques. Complications including bleeding and ductal injury appear to occur at a slightly higher rate than with traditional open cholecystectomy, but most surgeons who have had experience with the procedure predict that these complications will become rarer as more experience is gained. We may indeed be witnessing the first major successful challenge to traditional surgical management of symptomatic gallstone disease in 100 years.

The Angelchik prosthesis was devised as a simple surgical solution for reflux oesophagitis. Since 1983 there have been increasing reports of complications attributed to the prosthesis, the more serious being transmural erosion through the oesophageal or gastric wall. The majority of these have required repeat surgery, which is not without risks. A case report of an Angelchik prosthesis incompletely eroding into the stomach is presented. The prosthesis was tethered by a 1 cm-thick mucosal bridge which precluded simple extraction. Using an endoscopic sphincterotome, the bridge was divided and the prosthesis removed. Endoscopic methods of extracting intragastric Angelchik prostheses should be considered before surgery is undertaken for this complication.

The introduction of videoendoscopy has had a revolutionary impact on endoscopy teaching on a small scale within the Endoscopy unit itself and on a larger scale in the Conference Room which may be local or distant. The teaching of anatomy, pathology and endoscopic techniques have all been significantly affected and further improvements in electronic peripherals may make further image manipulation possible with further applications in teaching.

Methyl-tert-butyl-ether (MTBE), infused via a nasobiliary catheter, was used to treat 33 patients with bile duct stones in nine units around Britain. MTBE contributed to success in 12 (36 per cent) cases: seven passed stones spontaneously during MTBE infusion and five had partial stone dissolution allowing subsequent endoscopic extraction. MTBE was non-contributory in 21 (64 per cent) cases: four passed stones after MTBE was stopped, six were treated by subsequent endoscopic techniques without evidence of dissolution, seven underwent surgery, and four were treated conservatively (with one death). In at least ten of the 21 cases in which MTBE was non-contributory, pigment stones were present. Forty-two complications occurred in 26 (79 per cent) patients. The efficacy of MTBE for treating bile duct stones might be improved by better methods of instillation and, since success may be related to technique, the use of MTBE should be restricted to units familiar with this chemical.

Twenty-one patients with duodenal ulcer were treated with cimetidine. After 2 weeks they were submitted to an insulin test and the results were compared with a range of secretion previously established in untreated duodenal ulcer patients (1). The secretion of 13 patients fell within this range and so they were predicted to have a high risk of relapse. The patients whose secretion was below the range had a predicted low risk of relapse. After 4 weeks' treatment repeat endoscopy showed that 4 ulcers had failed to heal. The secretion of 3 of the patients was within the range of the high risk group. The remaining 17 patients were followed up (range 20-23 months): 9 relapsed and 8 remained symptom-free. Eight of the 9 were in the high risk group and 6 of the 8 symptom-free patients were in the low risk group. In all, 11 out of 13 were correctly predicted in the high risk group and 6 out of 8 in the low risk group. The performance of the insulin test in predicting liability to relapse following cimetidine treatment was significant (P = 0.0225).

The case is described of a young Asian woman with massive rectal haemorrhage during and after pregnancy. Barium radiology showed aphthoid ulcers in the colon and changes in the ileum suggesting tuberculosis. Colonoscopy revealed hyperplastic ulceration in the terminal ileum and culture of biopsies from this area grew Mycobacterium tuberculosis. The patient made a full and rapid recovery on anti-tuberculous therapy. Colonic aphthoid ulceration has not previously been recorded, radiologically, in intestinal tuberculosis.

One hundred and twenty patients with known common bile duct stones were entered into a prospective randomised study of preoperative endoscopic sphincterotomy and stone clearance (group 1) versus surgery alone (group 2). Five patients were incorrectly entered; the 55 patients randomised to group 1 and the 60 randomised to group 2 were well matched with respect to clinical features and biochemical and medical risk factors. In group 1 endoscopic stone clearance was successful in 50 patients (91%); five of these patients refused elective surgery, though this was subsequently necessary in one. In group 2 common bile duct stones were cleared surgically in 54 of 59 patients (91.5%); one patient was treated by endoscopic sphincterotomy alone because of a myocardial infarct. The overall major complication rate in group 1 was 16.4% and included two deaths; in group 2 this was 8.5% and included one death. The minor complication rate in group 1 was 16.4% and that in group 2 13.6%. These differences in outcome were not significant. Despite a significant reduction in total hospital stay of patients in group 1, these results do not support the routine use of preoperative endoscopic sphincterotomy in patients having biliary surgery for stones in the common bile duct.