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Preview Should surgery to remove gallstones be deferred until symptoms occur? When should therapy with oral bile acids, lithotripsy, or methyl tert-butyl ether be considered? How should nonspecific dyspeptic symptoms in a patient with cholelithiasis be managed? Dr Marshall discusses these and other questions and controversies.

Preview Although erythema infectiosum occurs primarily in children, the infection may be responsible for acute arthritis or arthralgia in adults. In this article, a case of acute symmetric polyarthritis affecting one of the authors is described. His symptoms were caused by parvovirus B19 infection, which was probably acquired from one of his children who had had erythema infectiosum a short time earlier.

Preview Medical and surgical choices for treating gastroesophageal reflux disease have never been better. In the last few years, potent medications have been introduced that suppress gastric acid production and have promotility effects, and laparoscopic approaches to antireflux surgery have been developed. In this article, Dr Marshall reviews current management techniques and explains how to decide which to recommend in a given patient with severe disease.

Background Polyethylene glycol (PEG) is a commonly used bowel preparation for colonoscopy. Unfortunately, the standard large-volume solution may reduce patient compliance. Split-dosing of PEG has been studied in various randomized, controlled trials (RCTs). However, results have been conflicting. Objective We conducted a meta-analysis to assess the role of split-dose PEG versus full-dose PEG for bowel preparation before colonoscopy. Design Multiple databases were searched (January 2011). RCTs on adults comparing full-dose and split-dose of PEG for bowel preparation before colonoscopy were included and analyzed by calculating pooled estimates of quality of bowel preparation, preparation compliance, willingness to repeat the same preparation, and side effects by using odds ratio (OR) by fixed and random-effects models. Setting Literature search. Patients Per RCTs. Main Outcome Measurements Satisfactory bowel preparation, willingness to repeat same bowel preparation, patient compliance, and side effects. Results Five trials met inclusion criteria (N = 1232). Split-dose PEG significantly increased the number of satisfactory bowel preparations (OR 3.70; 95% CI, 2.79-4.91; P P = .03) compared with full-dose PEG. Split-dose PEG also significantly decreased the number of preparation discontinuations (OR 0.53; 95% CI, 0.28-0.98; P = .04) and nausea (OR 0.55; 95% CI, 0.38-0.79; P Limitations Limited number of studies. Conclusions The use of a split-dose PEG for bowel preparation before colonoscopy significantly improved the number of satisfactory bowel preparations, increased patient compliance, and decreased nausea compared with the full-dose PEG.

Purpose Music has been utilized as a therapeutic tool during colonoscopy, but various randomized controlled trials (RCTs) have been inconsistent. We conducted a meta-analysis to analyze the effect of music on patients undergoing colonoscopy. Patients and Methods Multiple medical databases were searched (12/06). Only RCTs on adult subjects that compared music versus no music during colonoscopy were included. Meta-analysis was analyzed for total procedure time, dose of sedative medications (midazolam and mepiridine), and patients’ pain scores, experience, and willingness to repeat the same procedure in the future. Results Eight studies (N = 712) met the inclusion criteria. Patients’ overall experience scores (P < 0.01) were significantly improved with music. No significant differences were noted for patients’ pain scores (P = 0.09), mean doses of midazolam (P = 0.10), mean doses of meperidine (P = 0.23), procedure times (P = 0.06), and willingness to repeat the same procedure in future (P = 0.10). Conclusions Music improves patients’ overall experience with colonoscopy.

Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer

Background: There are few published data on how different types of colonoscopes affect success in reaching the cecum and patient comfort. We examined the feasibility of using a pediatric colonoscope for routine colonoscopy in adults and investigated whether there were subgroups of patients in whom use of this instrument was preferable. Methods: One-hundred fifty adults undergoing outpatient colonoscopy were randomized to colonoscopy with a standard colonoscope (Olympus CF-100L) or with a pediatric colonoscope (Olympus PCF-100). All procedures were performed by a faculty endoscopist and timed by an independent observer. After examinations, the endoscopist graded procedure difficulty and patients were given a questionnaire that assessed their experience. Results: The adult (n = 77) and pediatric (n = 73) colonoscope groups were comparable in all outcomes measured, including success in reaching the cecum (91% vs. 93%, p = 0.61), mean time to reach the cecum (11.4 vs. 9.7 min, p = 0.07), mean total procedure time (21.8 vs. 21.9 min, p = 0.95), mean meperidine dose (55 vs. 52 mg, p = 0.17); median midazolam dose (2.0 mg in both groups, p = 0.10), the endoscopists' perception of procedure difficulty, and patient comfort scales. Of the 7 patients in whom colonoscopy with the adult colonoscope was unsuccessful, the cecum was reached in 4 by switching to a pediatric colonoscope (all women, 3 of whom had prior hysterectomy). In the 5 patients in whom colonoscopy with the pediatric colonoscope was unsuccessful, the cecum was reached in 1 by switching to an adult colonoscope. Including the cases in which the cecum was reached by switching to the alternative colonoscope, the overall frequency of cecal intubation was 143 of 150 (95%). Subgroup analysis disclosed no difference between the 2 groups in outcomes when gender, presence of diverticulosis, and patient size were considered. Colonoscopy with the pediatric colonoscope was more successful than with the adult instrument in reaching the cecum in women with prior hysterectomy (11 of 12 [92%] vs. 15 of 21 [71%]); however, the numbers in each group were relatively small and the difference was not significant ( p = 0.22). Conclusions: The pediatric colonoscope is suitable for routine colonoscopy in adults. It is also useful in patients in whom colonoscopy with the adult colonoscope is unsuccessful in reaching the cecum (particularly in women). Additional study is needed to see if the pediatric colonoscope is actually superior to the adult colonoscopy for routine colonoscopy in women with prior hysterectomy. (Gastrointest Endosc 2000;51:314-7.)

We sought to determine the safety, efficacy, and outcome of percutaneous cholecystostomy (PC) in all patients undergoing the procedure at our institutions. We reviewed 53 consecutive cases of acute cholecystitis seen at our hospitals over 5.5 years in which PC was performed at the initial treatment. Follow-up was obtained by chart review and telephone questionnaire. Acute cholecystitis was the primary admitting diagnosis in 18 cases. In the remaining 35, cholecystitis developed during hospitalization. All patients were considered high surgical risks on the basis of the presence of comorbid conditions. The gallbladder was successfully catheterized under radiologic guidance in all patients and with no immediate procedure-related morbidity. Acute cholecystitis resolved in 44 of 53 patients (83%), whereas nine patients (17%) did not improve clinically after PC and died during the same hospitalization. A total of 33 (62%) eventually survived hospitalization. Elective cholecystectomy was done in 25 patients with no mortality. After cholecystectomy, three of these patients subsequently died of other causes, whereas 22 are alive. Eight patients did not undergo cholecystectomy because of underlying medical conditions or because they had acalculous cholecystitis. These patients remained free of biliary problems after removal of their cholecystostomy tube, but two have subsequently died of nonbiliary conditions. Percutaneous cholecystostomy is a safe, effective treatment for high-risk patients with acute cholecystitis. Cholecystostomy can be followed by elective cholecystectomy at a later time if the patient's condition permits or by expectant conservative management in patients who have had acalculous cholecystitis or have a very high mortality risk with surgery.

Objective: Open-access endoscopy allows physicians who are not gastroenterologists to directly schedule patients for endoscopic procedures without having them first seen in the gastrointestinal clinic. We sought to determine the prevalence of open-access endoscopy in the United States and to examine endoscopists' attitudes toward the practice. Methods: Questionnaires were mailed to a random sample of 1500 members of the American Society for Gastrointestinal Endoscopy. Out of 1460 that apparently reached the endoscopist, 577 (39.5%) were returned and analyzed. Results: Of the endoscopists who responded, 60.5% said that they offered some form of open-access endoscopy. Open-access endoscopy comprised less than 10% of outpatient endoscopic practice for 48.2% of individuals who reported they offered the service; it comprised over 25% of practice in 19.8%. Of those doing it, the procedures offered on an open-access basis included esophagogastroduodenoscopy 86.0%, colonoscopy 76.5%, flexible sigmoidoscopy 94.3%, ERCP 7.7%, and endoscopic ultrasonography 4.3%. For endoscopists not offering open-access endoscopy, the most important reasons were concern about performing "not indicated" procedures (85.1%), medical-legal issues (65.8%), and failure to believe in the concept of open-access endoscopy (59.6%). Attitudes toward open access endoscopy were significantly different among endoscopists who did and did not practice it. Conclusions: Open-access endoscopy, offered by more than 60% of the American endoscopists who responded to our survey, has become an important method of health care delivery in this country.(Gastrointest Endosc 1997;46:21-6)

Background: Documentation of total colonoscopy usually rests on a statement in the endoscopy report indicating that cecal landmarks were visualized. We sought to determine whether providing photographs of cecal landmarks provided an objective marker of complete colonoscopy. Methods: We had 12 outside experienced endoscopists review 120 photographs of cecal landmarks that had been included with colonoscopy reports from our center that included 20 consecutive cases of reported total colonoscopy from each of 6 endoscopists. Reviewers graded whether they believed each set of photographs documented that at least the cecal inlet was reached as definite, probable, or uncertain. Results: There was considerable disparity among reviewers as to whether individual photographs documented total colonoscopy. The frequency of combined, definite, and probable scores that they gave for the 120 photographs ranged from 97% down to 44% (median 82%). Different endoscopists also seemed to be variably successful in photodocumenting total colonoscopy. Four of the endoscopists received definite and probable scores for their 20 cases at least 80% of the time (86% for the highest ranked endoscopist). The lowest ranked endoscopist received such scores just 64% of the time. Conclusions: Documenting total colonoscopy with static images of cecal landmarks is only partially successful as an objective measure of the extent of total colonoscopy. (Gastrointest Endosc 1996;44:243-8.)

Background and purpose: We sought to provide an objective measure of the technical progress of trainees learning colonoscopy. GI fellows in our training program perform colonoscopy under supervision throughout their 2 years of fellowship. Method: The frequency of fellows reaching the cecum in less than 30 minutes was determined by one endoscopy instructor during the last 7 months of their first year of training and during the last 7 months of their second year. Results: The mean success rate of reaching the cecum for seven first-year fellows was 54% (individual range, 25% to 86%). This compared with 86% for six second-year fellows (individual range, 73% to 93%) and with 97% for the endoscopy instructor when he did procedures without a fellow. First-year fellows during the 7-month "testing" periods believed they had reached the cecum in 5.7% of cases in which they had not. This was not a problem with second-year fellows. Counting colonoscopies done with all instructors in our program, fellows in this series each did an average of 149 colonoscopies during their first-year of training and 328 by the end of their second. Conclusions: Increasing proficiency in reaching the cecum occurs with experience over time, and continues even after completion of formal training. Individual trainees also seem to learn colonoscopy at different rates. Depending on how one defines competency, it is possible that the minimum threshold number for technical competency in colonoscopy of 100 procedures, as suggested by the ASGE, may be low. (Gastrointest Endosc 1995;42:287-91.)

We investigated the effect of droperidol on objective markers of cooperation and vital signs in 140 patients undergoing elective diagnostic esophagogastroduodenoscopy. Procedure duration and the total doses of midazolam and meperidine required during the procedure were evaluated as objective markers of patient cooperation. The droperidol group comprised 66 patients and the placebo group 74 patients. Patient and procedure characteristics were similar for both groups. Droperidol produced a 10% reduction in procedure duration. Linear multiple regression modeling revealed droperidol to be a significant predictor of procedure duration (p = .036). Droperidol significantly reduced midazolam and meperidine requirements (p.01). Nonetheless, four patients in the droperidol group received naloxone to reverse prolonged, excessive drowsiness. Droperidol produced a significant reduction in procedure-associated increase in pulse rate but did not exacerbate procedure-associated reduction in mean arterial pressure. Droperidol favorably influences markers of patient cooperation during elective, diagnostic esophagogastroduodenoscopy. However, the clinical significance of these changes is unclear.

Systemic lupus erythematosus presents various clinical manifestations. The coexistence of systemic lupus erythematosus and celiac sprue has been rarely reported. We present a patient who had systemic lupus erythematosus with malabsorption demonstrating characteristic clinical and pathologic findings of celiac sprue (gluten enteropathy).

Severe gastroesophageal reflux disease is usually a chronic problem with periods of relapse, but effective medical and surgical therapies are available. Two recently introduced agents, omeprazole (Prilosec) and cisapride (Propulsid), represent advances in medical therapy; the safety of long-term, continuous omeprazole therapy is under investigation. Used by surgeons with sufficient experience, the new laparoscopic approach offers potential advantages over conventional anti-reflux surgery in suitable candidates. The decision of whether to recommend long-term medical therapy or surgery must be individualized. Medical therapy may be the best choice in elderly patients and poor surgical candidates, in patients whose symptoms are well controlled with omeprazole and who accept its benefit-risk profile, and when a highly experienced anti-reflux surgeon is not available. Surgery may be appropriate (assuming a skilled surgeon is available) in patients who are young, have trouble taking medication, need multiple agents to control symptoms, and need continuous omeprazole therapy but are unwilling to accept the theoretical risk of gastric carcinoid tumors that accompanies it. Language: en

Background: Several recent trials have shown that colonoscopy preparation with sodium phosphate solution is as effective and at least as well tolerated as conventional PEG-ES lavage. These trials utilized two 1.5-fluid oz doses, one given on the evening before colonoscopy and the other early the next morning. Methods: We devised a new sodium phosphate regimen in which the entire dose was given on the evening before examination (1.5 fl oz at 4 pm, 1.5--fl oz at 7 pm and 10 mg of bisacodyl at 10 pm) and performed a prospective, randomized trial that compared it with conventional PEG-ES lavage in terms of quality of colon cleansing, patient tolerance, and safety in an outpatient colonoscopy population with normal renal function. Seventy-two patients received sodium phosphate-bisacodyl and 75 PEG-ES lavage. Results: The overall quality of colon cleansing and frequency of unsatisfactory preparations were similar with both methods. Patients found preparation with sodium phosphate-bisacodyl to be easier than PEG-ES lavage ( p =0.005). No clinically important adverse effects were seen with either method of preparation. The average cost of sodium phosphate-bisacodyl was $4.32 per patient compared with $18.15 for PEG-ES lavage preparation. Conclusion: Preparation with sodium phosphate-bisacodyl, given on the evening before colonoscopy, is a well-tolerated, efficacious, and cost-effective alternative to conventional PEG-ES lavage.

Physicians are familiar with the "slapped cheek" rash seen in childhood cases of erythema infectiosum. Less well known is that infection with its pathogen, parvovirus B19, often becomes manifest in adults as acute viral arthropathy. In evaluation of suspected cases, a complete blood cell count and blood chemistry profile are useful additions to thorough history taking and physical examination. Differential diagnosis includes Lyme disease, other viral infections, acute rheumatoid arthritis, systemic lupus erythematosus, and psoriatic arthritis. Treatment is symptomatic with nonsteroidal anti-inflammatory drugs.

Recent advances in our understanding of the natural history of gallstones and the introduction of new treatment options have dramatically altered the approach to gallstone management. Most patients with cholelithiasis are asymptomatic, and for them, expectant management is now recommended by many authorities. This approach may also be acceptable for some patients who have only occasional episodes of biliary colic. Laparoscopic cholecystectomy is preferred for patients who have had repeated episodes of biliary colic or acute cholecystitis and who are suitable operative candidates. Nonsurgical options include oral dissolution therapy with bile acids, extracorporeal shock wave lithotripsy, and contact dissolution with methyl tert-butyl ether. Each has significant limitations but may be considered for selected patients with symptomatic gallstones who are not candidates for general anesthesia or who refuse surgery. Future improvements in nonsurgical therapies may ultimately expand their use.

The spectrum of acute pancreatitis can range from mild and self-limited to severe and fatal. A number of aspects of the condition remain poorly understood or controversial, although recent advances have improved our understanding in many areas. A substantial number of cases of "idiopathic" acute pancreatitis may be caused by occult biliary microlithiasis. The mechanism by which enzymes and bioactive substances become activated within the pancreas is a major unanswered question in acute pancreatitis; however, recent studies suggest that lysosomal enzymes within the pancreatic acinar cell may play a role. A recent refinement in computed tomography, contrast-enhanced dynamic pancreatography, has shown itself to be an extremely useful tool for detecting pancreatic necrosis and its extent, which correlates with the severity of pancreatitis and is useful in identifying patients who may have pancreatic infection and other complications. The management of acute pancreatitis includes supportive measures, observation for development of complications, and the identification of the cause of pancreatitis to prevent recurrences. Specific treatments introduced with the goal of halting the cycle of pancreatic autodigestion and benefiting the course of pancreatitis have generally proved ineffective. Early aggressive treatment of biliary pancreatitis remains controversial; however, endoscopic sphincterotomy may be helpful in more severe cases of biliary pancreatitis if there is no clinical improvement over 48 to 72 hours. Computed tomography—guided percutaneous needle aspiration appears to be a safe and reliable method for diagnosing infected pancreatic necrosis, pancreatic abscess, and infected pancreatic fluid collections. (Arch Intern Med. 1993;153:1185-1198)

We review our institution's experience with gastrointestinal (GI) carcinoid tumors over the past three decades: fifty-five cases with complete follow-up. The majority of carcinoids were from the ileum and appendix--19 cases (35%) and 17 cases (31%), respectively. Other locations included the cecum in five (9%), duodenum in three (5%), jejunum in three (5%), rectum in three (5%), and pylorus in one (2%). Four patients had metastatic carcinoid of uncertain primary (7%). Appendiceal carcinoids were frequently incidental and small (all < 1 cm). None were metastatic, and all appeared to have been cured with simple appendectomy. In contrast, ileal carcinoids were usually symptomatic and often metastatic at the time of diagnosis. Carcinoid syndrome occurred in 10 patients (18%), associated primarily with metastatic tumors from the ileum and cecum. Secondary malignancies were seen in 10 patients (18%). We provide a literature survey of GI carcinoid tumors and carcinoid syndrome.

Paraesophageal herniation is a potentially devastating condition of the gastroesophageal hiatus commonly manifesting in patients of advanced age with other significant medical problems. Surgical treatment is generally indicated to avoid catastrophe related to gastric volvulus. The operative approach utilized should be individualized to the patient's pathophysiologic condition rather than attempting to apply a single repair for all patients with this heterogeneous clinical problem.

Bleeding from esophagogastric varices carries a high mortality rate. Active variceal bleeding can usually be temporarily controlled medically with a combination of intravenous vasopressin and nitroglycerin, with balloon tamponade, or with endoscopic sclerotherapy. Because of the high likelihood of recurrence, long-term treatment, such as repeated sclerotherapy, propranolol therapy, or shunt surgery, is necessary. The proper selection of such measures requires consideration of the site of variceal bleeding, local availability of specialized techniques, and patient factors. Only liver transplantation reverses the liver damage and offers hope of improved long-term survival. As success at identifying high-risk patients by endoscopic features improves, propranolol or other pharmacologic prophylaxis may become an acceptable treatment.

Recipients of renal transplants are known to have an increased incidence of cancer, which is believed to be related to the use of immunosuppressive drugs used to prevent rejection. Although the risks of lymphoma and Kaposi's sarcoma are clearly increased in this setting, the association with colon cancer is controversial. We report a 44-yr-old woman, 20 yr post-renal transplant, and with no family history of colorectal cancer or polyps, who was found to have synchronous, poorly differentiated colon cancers associated with extensive abdominal lymph node, bone marrow, and bone (skull) metastasis. The long term immunosuppressive drugs that she had received may have been an important factor in her tumor development and/or progression. Our case and literature review suggest a possible mild, increased risk of colon cancer development in patients after renal transplantation.

Biliary-type pain from sphincter of Oddi dysfunction is not uncommon after cholecystectomy. An increased basal pressure of sphincter of Oddi manometry establishes the diagnosis and treatment is usually by endoscopic sphincterotomy. Both procedures carry a significant complication rate. A few patients with elevated sphincter pressure do not respond to therapy; the source of their pain may be elsewhere. This case report describes the use of intrasphincteric botulinum toxin injection for the diagnosis of sphincter of Oddi dysfunction in a patient after repeated attempts at manometry had failed. This may provide a safe and easy method of determining whether sphincter of Oddi dysfunction may be the cause of biliary pain in post/ cholecystectomy patients and help select patients who would benefit from subsequent sphincter ablation, without the risks of sphincter of Oddi manometry. Prospective studies are first needed.

Purpose: Prophylactic antibiotics have been used in acute necrotizing pancreatitis with mixed results. This meta-analysis analyzes the effects of prophylactic antibiotics in necrotizing pancreatitis. Methods: Multiple databases and abstracts were searched for randomized trials comparing treatment with prophylactic antibiotics to treatment without prophylactic antibiotics in necrotizing pancreatitis. Prophylactic antibiotics' effects were analyzed by calculating pooled estimates of mortality, infected pancreatic necrosis, length of hospital stay, nonpancreatic infections, and surgical intervention. Results: Seven studies (n = 429) met the inclusion criteria. Prophylactic antibiotics for acute necrotizing pancreatitis significantly decreased the length of hospital stay (P = 0.04) and the rate of nonpancreatic infections (P < 0.01). No significant differences were noted for mortality (P = 0.22), infected necrosis (P = 0.18), and surgical intervention (P = 0.40). Conclusions: Prophylactic antibiotics in necrotizing pancreatitis reduced the length of hospital stay and rate of nonpancreatic infections but did not decrease mortality, infected necrosis, or surgical intervention.

We examined the gastrointestinal tract abnormalities in 61 patients with mixed connective tissue disease. The first 34 were part of a prospective longitudinal study that included manometric and radiographic evaluation of the esophagus. Heartburn (48%) and dysphagia (38%) were by far the most common gastrointestinal symptoms. Seventeen percent of patients undergoing manometry had distal esophageal aperistalsis, and 43% low-amplitude peristalsis (less than 30 mmHg). Studies in 10 patients before and after treatment suggested that esophageal dysfunction in mixed connective tissue disease may be responsive to corticosteroids. Upper esophageal sphincter hypotension was also common. One patient had marked upper esophageal sphincter hypotension and recurrent aspiration, which resolved with corticosteroid therapy. Findings on radiographic studies of the stomach and small bowel in 54 patients and barium enemas in 16 patients were reviewed. Our series included one case each of malabsorption, colonic and small bowel perforations due to vasculitis, chronic active hepatitis, and acute pancreatitis. In conclusion, any area of the gastrointestinal tract may be affected by mixed connective tissue disease, although the esophagus is the most common location. The gastrointestinal aspects of mixed connective tissue disease overlap with those of progressive systemic sclerosis, polymyositis, and systemic lupus erythematosus.

Although achalasia is usually of idiopathic origin, it may be secondary to another disease process such as neoplasia. The first description of a familial achalasia syndrome that appears to be secondary to diffuse esophageal leiomyomatosis with entrapment of nerve ganglia is presented. Documented in four generations of a family, the disease followed an autosomal dominant mode of inheritance. Long lower esophageal sphincter pressure zones and a high incidence of epiphrenic diverticula were interesting accompaniments of achalasia in this family. Many achalasia affected family members have also had associated intestinal leiomyomas or neurofibromas. Affected family members also had urticaria pigmentosa, and some had systemic mast cell disease as well.

We report a patient with classical features of amiodarone hepatotoxicity who died of progressive liver failure. Throughout the course of his illness, he had epigastric pain, nausea, vomiting, and persistent mild to moderate elevation of amylase and lipase in his serum and peritoneal fluid. Pancreatitis due to amiodarone has not been reported. We raise the question of whether or not the pancreas is yet another organ subject to amiodarone toxicity and speculate as to possible pathogenesis. We suggest that patients on amiodarone who develop abnormal liver enzymes, nausea, vomiting, or abdominal pain be evaluated not only for hepatotoxicity, but for pancreatitis as well.

SpyGlass (Microvasive Endoscopy, Boston Scientific Corp, Natick, Mass) is a recently introduced system designed to permit single-operator cholangioscopy and pancreatoscopy. The system consists of a disposable access and delivery catheter that can be steered, a reusable fiberoptic visualization probe, and a disposable biopsy forceps, all of which can be passed through a duodenoscope at the time of ERCP. It was designed for direct cholangiopancreatoscopic applications, and its use, in conjunction with EUS, has not been reported. We report a case in which SpyGlass was used in conjunction with EUS to inspect and biopsy the inside of a pancreatic cystic lesion via the stomach. This may be the first of a number of EUS-assisted transluminal endoscopic applications of SpyGlass.

AIM: To evaluate the effect of relaxing music during colonoscopy under low-dose conscious sedation, on patient satisfaction, scope insertion time and procedure duration, medication doses, and the perceived adequacy of sedation and scope insertion difficulty on the part of the endoscopist. METHODS: One hundred and sixty-seven consecutive adult outpatients presenting for routine colonoscopy under low-dose conscious sedation were randomized to undergo their procedures either with music played during the procedure or no music played. RESULTS: There were no statistical differences between the two groups in terms of meperidine dose, midazolam dose, time to reach the cecum, total procedure time, endoscopist assessment of scope insertion difficulty, endoscopist assessment of adequacy of sedation, or the pain experience of the patients during their procedure. The music group did report significantly better overall procedure satisfaction as compared to the non music group on two of our three different scales. CONCLUSION: While music does not result in shortened procedure times, lower doses of sedative medications or perceived patient pain, the patients who have music playing during their procedures report modestly greater satisfaction with their procedures.

Purpose Screening by digital rectal exam (DRE) has been advocated as a means of detecting early-stage prostate cancer. We sought to determine the adequacy of prostate palpation at DRE at colonoscopy, and to devise a method of improving adequacy when the gland is incompletely felt. Materials and Methods Adequacy of prostate palpation in the left lateral position was prospectively assessed in 200 males 40 years or older undergoing colonoscopy, and correlated with body mass index (BMI) and National Institutes of Health (NIH) weight categories. If the prostate was incompletely felt, the patient was asked to flex his knee(s) up toward his chest, and then the exam was repeated. Results The prostate was incompletely felt on initial DRE in 65 of 200 patients (32.5%). Raising the knee(s) toward the chest permitted complete palpation in 62 of those 65 cases. Incomplete palpation showed a strong correlation with BMI (P

Newer percutaneous endoscopy gastrostomy (PEG) tubes with soft internal bolsters may be prone to accidental dislodgement or removal by patients. When this occurs after a mature gastrocutaneous fistula has formed, it is of little consequence as long as a replacement tube is promptly reinserted before the track closes. Blind reinsertion of a replacement tube before the track is adequately mature may have serious consequences, as exemplified by a patient who developed peritonitis as a result of inadvertent insertion into the peritoneal cavity. We managed two other patients with early accidental PEG tube removal by a period of nasogastric (NG) suction, intravenous antibiotic drugs, and observation, with a new tube placed endoscopically 7-9 days later. We review the management of early, inadvertent dislodgement of PEG tubes.

Colonoscopy can be difficult in some women who have undergone hysterectomy, which can be associated with a fixed, angulated sigmoid colon caused by postoperative pelvic adhesions. Our goal was to determine whether colonoscopy is easier and more comfortable for women after hysterectomy when performed with a pediatric colonoscope, which is thinner in diameter and more flexible than a standard "adult" colonoscope.One hundred women with a history of hysterectomy undergoing outpatient colonoscopy were randomized in unblinded fashion to colonoscopy with a standard colonoscope (CF-100L or CF-Q140L, Olympus) or with a pediatric colonoscope (PCF-100, Olympus). All procedures were performed by a faculty endoscopist and timed. After examination, the endoscopist graded procedure difficulty, and patients were given a questionnaire that assessed their experience.The cecum was intubated more frequently in the pediatric colonoscope group than in the standard colonoscope group (96.1% vs. 71.4%, p0.001). Success increased in the standard colonoscope group to 89.8% when the pediatric colonoscope was used to complete the examination. There were no differences in the two groups in terms of mean total procedure times (21.4 minutes vs. 22.6 minutes), mean doses of meperidine administered (57 mg both groups), mean doses of midazolam administered (1.5 mg vs. 1.7 mg), scales of procedure difficulty as graded by the endoscopists, and comfort scales as graded by patients. For the cases in which the cecum was intubated, the mean time to reach the cecum (11.7 minutes for the pediatric colonoscope group vs. 12.7 minutes for the adult) was similar.The pediatric colonoscope is a reasonable choice for colonoscopy in women who have had a hysterectomy. Alternatively, if the endoscopist elects to start the procedure with a standard colonoscope, it is helpful to have a pediatric colonoscope available for use should a fixed, angulated sigmoid colon be encountered that cannot be easily or safely traversed with the standard colonoscope.

We examined the frequency of total colonoscopy and terminal ileal intubation in a training setting using modern videoendoscopic equipment and techniques with examinations supervised or done by the two authors. The cecum was considered reached if the endoscopic report included a description of the cecal landmarks visualized and if electronic images documenting these landmarks were obtained. One of us also routinely attempted terminal ileal intubation for documentation purposes, allotting a minute or two for the purpose. In cases of chronic diarrhea and possible inflammatory bowel disease, a more prolonged attempt was made to visualize the terminal ileum. Among 418 consecutive colonoscopies, the cecum was reached in 96% of cases. If cases of malignant obstruction were excluded, the success rate improved to 97%. When routinely attempted, the terminal ileum was intubated and inspected in 74% of cases (excluding cases of malignant obstruction). In cases in which terminal ileal intubation and inspection was deemed necessary, the success rate was 91%. We conclude that total colonoscopy can be accomplished in the 1990s in excess of 90% of cases and can be documented by high-quality photographs that can be attached to the procedure report. High rates of successful total colonoscopy should be attainable even in training programs. Routine intubation of the terminal ileum can be performed to provide further objective proof of the extent of colonoscopy and to allow the endoscopist to develop and maintain the skill. A skilled, practiced endoscopist can inspect the terminal ileum in about 90% of cases in which such examination is needed.

Biliary-type pain from sphincter of Oddi dysfunction is not uncommon after cholecystectomy. An increased basal pressure of sphincter of Oddi manometry establishes the diagnosis and treatment is usually by endoscopic sphincterotomy. Both procedures carry a significant complication rate. A few patients with elevated sphincter pressure do not respond to therapy; the source of their pain may be elsewhere. This case report describes the use of intrasphincteric botulinum toxin injection for the diagnosis of sphincter of Oddi dysfunction in a patient after repeated attempts at manometry had failed. This may provide a safe and easy method of determining whether sphincter of Oddi dysfunction may be the cause of biliary pain in post/ cholecystectomy patients and help select patients who would benefit from subsequent sphincter ablation, without the risks of sphincter of Oddi manometry. Prospective studies are first needed.

Surgical treatment of peptic stricture of the esophagus associated with columnar (Barrett) metaplasia can be a difficult problem. Collis-Nissen fundoplication restores an intraabdominal antireflux barrier for most cases of peptic stricture; however, 20% of patients may have persistence of pathological acid reflux. By reducing acidity of postoperative reflux, parietal cell vagotomy may complement nonresectional surgical results for Barrett stricture.

Background: We sought to determine whether premedication for colonoscopy with intravenous hyoscyamine sulfate (Levsin) was helpful from the standpoint of the colonoscopist and the patient. Methods: One hundred sixteen adult patients were randomized to receive either 0.5 mg hyoscyamine sulfate intravenous (n = 57) or placebo (n = 59). After administration of study drug, patients were given meperidine and midazolam. Parameters measured included the time required to reach the cecum, total procedure time, and the endoscopist's perception of the adequacy of sedation, difficulty of insertion, and amount of colonic spasm on insertion and withdrawal. Patients were given a postprocedure questionnaire assessing their experience. Results: In patients receiving hyoscyamine, there was a shorter cecal intubation time (median 9.2 vs. 12.9 minutes; p = 0.01), shorter total colonoscopy time (median 20.5 vs. 25.0 minutes; p = 0.01), better patient sedation ( p = 0.02), easier colonic insertion ( p = 0.001), and less spasm on insertion ( p = 0.01). No difference was found in the amount of spasm during withdrawal or the total dosages of meperidine or midazolam used. Patients receiving hyoscyamine sulfate reported being more comfortable during their procedures ( p p = 0.0001). The only adverse effect seen during the study was a 27% incidence of sinus tachycardia that occurred in patients receiving hyoscyamine. Conclusions: Premedication with intravenous hyoscyamine sulfate was beneficial in terms of the time required for cecal intubation, total procedure time, adequacy of sedation, and scales of patient comfort. However, the high frequency of sinus tachycardia seen with the dose used in our study, which was extremely rapid in two patients, indicates the need for further study before the drug can be recommended as a routine premedication for colonoscopy. (Gastrointest Endosc 1999;49:720-6.)

Recent decades have seen an increase in publications in English from the international community in basic science journals, as well as in general and specialty medical journals.1–6 However, to date, no one has examined the international publishing trends in gastroenterology and hepatology journals. We examined the extent of internationalisation in this field with regard to high-quality research publications over the period 1970–2005. Additionally, earlier studies discussing internationalisation of biomedical literature did not deal with the impact of multinational collaborations (articles involving authors from two or more countries). Thus, our secondary aim was to describe changes in multinational research publications during this period. We reviewed the three highest-ranked gastroenterology journals based on journal impact factor and total literature citations for 2005: Gastroenterology , Hepatology and …

We examined a number of patient variables, including three different scales of preprocedure patient anxiety, to determine which best predicted patient cooperation and satisfaction with gastrointestinal endoscopy. We prospectively evaluated 251 patients undergoing outpatient diagnostic esophagogastroduodenoscopy and colonoscopy under conscious sedation. All were given a questionnaire on arrival to our endoscopy center that included three measures of preprocedure anxiety: (a) a single question asking how anxious the patient was (termed "Anxiety I" scale); (b) a visual linear analog scale of anxiety; and (c) the Hospital Anxiety and Depression scale. Patient cooperation during the procedure was rated by the attending endoscopist. Patients were telephoned the next day to complete a questionnaire assessing their endoscopic experience. Logistic regression analysis was used to construct models for predicting which patients were most likely to have difficulty during their procedures from both the endoscopists' and the patients' standpoint. Statistical analysis identified three parameters that by themselves significantly correlated with patient cooperation during endoscopy: age (p = 0.008), Anxiety I scale (p = 0.03), and visual linear analog anxiety score (p = 0.02). When used together, age, type of procedure, and Anxiety I scale were the best predictors of patient cooperation from the standpoint of the endoscopist. Age, type of procedure, Anxiety I scale, and education level were the best predictors of satisfaction with endoscopy from the perspective of the patient. Good cooperation during endoscopy was associated with greater patient satisfaction.