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Physicians involved in the management of patients with chronic hepatitis B infection are frequently faced with complex clinical issues concerning the diagnosis, investigation, and treatment of patients. Guidelines exist within the literature that help with decision making; however, in practice individual nuances are often encountered necessitating decisions that go beyond the current guidelines. Following presentation of the available data, a panel of expert hepatologists and gastroenterologists sought to identify and solve challenges that are faced by clinicians in the daily management of patients with chronic hepatitis B infection. The following summary provides an overview of the outcome of these discussions. Because of the complexities of clinical management, the recommendations reflect the opinion of the majority; however, many recommendations were not unanimous. Furthermore, the recommendations that follow are limited to adult patients; the treatment of children was not discussed. A number of issues were identified, and statements concerning possible management strategies that could be applied were developed.

The esophageal complications of gastroesophageal reflux disease (GERD) are well described and include erosive esophagitis, stricture, Barrett esophagus, and adenocarcinoma. Primary care physicians often encounter patients with "extraesophageal" manifestations of GERD in the absence of heartburn. Patients may present with symptoms involving the pulmonary system, noncardiac chest pain, and ear, nose, and throat disorders. The diagnosis of reflux disease in these individuals may be challenging because, in addition to the absence of heartburn, endoscopy is often negative. Laryngoscopy and 24-hour dual-channel intraesophageal pH-metry may have greater diagnostic yields, but they are costly, invasive, and time-consuming. A trial of proton pump inhibitor (PPI) therapy is increasingly being considered a first-line diagnostic test in those with suspected reflux-related extraesophageal symptoms. The duration as well as dose of PPI should be based on the presenting symptoms, with patients having pulmonary manifestations often requiring twice-daily therapy for 2 to 3 months. In contrast, symptoms of reflux-related noncardiac chest pain may be relieved with a 1-week, standard-dose treatment trial. Patients who fail to experience symptom resolution or improvement should undergo further diagnostic evaluations including 24-hour esophageal pH studies while continuing their PPI therapy to establish persistent versus absent acid reflux. The role of fundoplication or other surgical/laparoscopic procedures in these patients has yet to be determined.

A freestanding ambulatory surgery center (ASC) at an academic institution is an exception rather than the rule. It is a major challenge to the concept of the traditional academic medical center. Advantages and disadvantages are discussed, as well as the detailed planning process beginning with a well executed feasibility study, the hiring of consultants, and financing of the facility. Construction, opening of the facility and operation are not different from other ACSs. However, the integration of teaching and research presents new opportunities. Lessons learned and advice to others are detailed on how the ASC benefitted one specific institution and how it may add value and revenue to other academic medical centers.

We report herein the results of extended follow-up of an expanded randomized clinical trial comparing transjugular intrahepatic portosystemic shunt (TIPS) to 8 mm prosthetic H-graft portacaval shunt as definitive treatment for variceal bleeding due to portal hypertension. Beginning in 1993, through this trial, both shunts were undertaken as definitive therapy, never as a "bridge to transplantation." All patients had bleeding esophageal/gastric varices and failed or could not undergo sclerotherapy/banding. Patients were excluded from randomization if the portal vein was occluded or if survival was hopeless. Failure of shunting was defined as inability to shunt, irreversible shunt occlusion, major variceal rehemorrhage, hepatic transplantation, or death. Median follow-up after each shunt was 4 years; minimum follow-up was 1 year. Patients undergoing placement of either shunt were very similar in terms of age, sex, cause of cirrhosis, Child's class, and circumstances of shunting. Both shunts provided partial portal decompression, although the portal vein-inferior vena cava pressure gradient was lower after H-graft portacaval shunt (P < 0.01). TIPS could not be placed in two patients. Shunt stenosis/occlusion was more frequent after TIPS. After TIPS, 42 patients failed (64%), whereas after H-graft portacaval shunt 23 failed (35%) (P < 0.01). Major variceal rehemorrhage, hepatic transplantation, and late death were significantly more frequent after TIPS (P < 0.01). Both TIPS and H-graft portacaval shunt achieve partial portal decompression. TIPS requires more interventions and leads to more major rehemorrhage, irreversible occlusion, transplantation, and death. Despite vigilance in monitoring shunt patency, TIPS provides less optimal outcomes than H-graft portacaval shunt for patients with portal hypertension and variceal bleeding.

Diagnostic laparoscopy continues to play an important role in the accurate evaluation of patients with abdominal disorders. Combined with laparoscopic ultrasound, it is highly accurate in the staging of intra-abdominal malignancies, and it is superior to transcutaneous ultrasonography and computed tomography. Other important applications include the evaluation of patients with acute and chronic abdominal pain, acute abdomen, peritonitis, and blunt and penetrating abdominal trauma. Laparoscopy now rests firmly in the hands of surgeons. The majority of last year's papers originated from departments of surgery; papers on laparoscopy in hepatic disorders are sorely missing in this year's review.

Liver biopsy remains an essential tool to confirm a suspected diagnosis and guide specific therapy in patients with liver disease. The methods available to obtain liver tissue include percutaneous needle biopsy, transjugular biopsy, image-guided needle biopsy, and laparoscopic direct vision guided needle biopsy. Advantages and disadvantages of each modality are reviewed herein. The indications for liver biopsy include evaluation of elevated aminotransferases, assessment of response to therapy of chronic liver disease, monitoring for hepatoxicity of drug therapy, and liver transplant allograft evaluation. Contraindications include impaired coagulation, significant ascites, high-grade extrahepatic biliary obstruction, echinococcal cyst, and certain anatomic abnormalities. Complications include pain, hemorrhage, bile peritonitis, penetration of abdominal viscera, pneumothorax, and death. Complications are reported in 0.06-0.32% of the patients. Death as a direct result of liver biopsy is extremely rare (0.009-0.12%). In properly selected patients, liver biopsy has a high benefit/risk ratio and is often considered the final and definitive diagnostic test.

We endoscopically evaluated odynophagia and/or dysphagia in 23 patients with acquired immunodeficiency syndrome (AIDS). Eleven patients (48%) were found to have esophageal ulcers. Seven of them had deep, sharply demarcated, well-circumscribed ulcer craters with raised edges; in two the ulcer extended to the muscularis propria. Ulcers were single in four patients, multiple in six, and unspecified in one. Biopsies were nondiagnostic. In eight patients, mycobacterial, viral, and fungal cultures were negative. Specific infections diagnosed in three patients were treated with appropriate agents. Ulcers were treated symptomatically, and seven patients received therapy for suspected viral etiology. Symptoms remained unchanged in five patients, improved in three, and resolved in two. Fifty-five percent of patients died within 3.6 months (mean) of diagnosis. Large solitary and multiple esophageal ulcers are common in AIDS patients with odynophagia and dysphagia.

Non 0-1 Vibrio cholerae infection is often associated with ingestion of contaminated seafood and its common presentation is gastroenteritis. Septicemia may be found in immunocompromised hosts resulting in mortality approaching 50%. A case is reported of non 0-1 Vibrio cholerae infection presenting with septicemia in a patient with neutrocytic ascites suggestive of spontaneous bacterial peritonitis.

We report four cases of niacin-induced hepatotoxicity. All four patients were using sustained-release niacin preparations. When they stopped taking niacin, symptoms and laboratory abnormalities resolved. Two of the patients had focal fatty infiltration of the liver on imaging studies, a presentation of niacin hepatotoxicity not previously described. One patient had a coagulopathy even though aminotransferase levels were only mildly elevated. We recommend that patients using sustained-release preparations of niacin have periodic monitoring of liver enzymes and that the preparation be discontinued if any abnormalities develop.

Diminutive polyps are frequent findings on screening flexible sigmoidoscopy. To determine the significance of distal diminutive polyps, we conducted a prospective study of 162 asymptomatic, average-risk subjects who were 50 years of age or older. Subjects were divided into four groups: 42 control subjects with no polyps in the rectosigmoid, 66 subjects with at least one diminutive adenoma in the rectosigmoid, 12 subjects with a mixed hyperplastic-adenomatous polyp in the rectosigmoid, and 42 subjects with only hyperplastic polyps in the rectosigmoid. Total colonoscopy was performed on all subjects. The prevalence of proximal adenomas was 42% in the adenoma group, 25% in the mixed group, 14% in the hyperplastic group and 12% in the control group. The prevalence of proximal adenomas was significantly higher (p = 0.006) in the adenoma group as compared with the control and hyperplastic groups. Increasing age was associated with an increased prevalence of proximal adenomas. Nearly two thirds of those over 65 years of age with distal diminutive adenomas had proximal colonic neoplasms. These results indicate that diminutive rectosigmoid adenomas are good markers for proximal neoplasms. Rectosigmoid hyperplastic polyps are not associated with an increased prevalence of proximal neoplasms. Total colonoscopy is not indicated if hyperplastic polyps are the only finding on flexible sigmoidoscopy.

Laparotomy performed for bleeding duodenal ulcer after diagnostic/therapeutic endoscopy revealed a disparity in location of the lesion on several occasions at our institution. The position of the duodenal lesion is important in assessing bleeding potential. Twenty consecutive patients underwent upper gastrointestinal endoscopy by a staff and trainee gastroenterologist to evaluate the ability to determine the true posterior position of the duodenal bulb. Documentation of the posterior bulb location was verified by pooled colored fluid with the patient in a supine position. True posterior location was chosen only 30% of the time by an experienced gastroenterologist. This observation may have clinical implications in assessing the patient's bleeding potential and in the use of coaptive coagulation for control of ulcer bleeding.

This is a retrospective review of our experience with fiberendoscopic management of 40 separate episodes of foreign body ingestion. Eighteen patients swallowed a food bolus which impacted in the esophagus. Seventy-eight percent of these patients had an esophageal stenosis. Sixteen patients were involved in 22 episodes of true foreign body ingestion. Fiberendoscopic management was successful in 92% of food impactions and 76% of true foreign bodies. In our experience, fiberendoscopic removal is a safe procedure with an 83% overall success rate. It is the method of choice in the management of esophageal and gastric foreign bodies.

Four cases of esophageal rupture associated with the use of the esophageal obturator airway are presented and added to the fifteen cases already in the literature. The incidence of this complication may be greater than previously suspected since a systematic search for this complication has not been made in cardiac arrest patients. The mechanism of rupture of the occluded esophagus may be similar to that seen in postemetic rupture. Endotracheal intubation remains the procedure of choice in airway control of cardiac arrest patients, although the modified esophageal obturator airway with gastric tube may prevent the occurrence of esophageal rupture by allowing decompression of the esophagus.

This study was performed to develop a system to measure dysphagia in an objective fashion, test its correlation with subjective estimates of dysphagia, and encourage the use of a standardized measure of esophageal stenosis. Thirty-five patients with mechanical dysphagia underwent subjective estimates of dysphagia using a dysphagia scale graded from 0 to 5, as well as a diet scale. Lumen diameter was measured endoscopically, using the open or closed biopsy forceps as a measuring guide. Patients were then given barium capsules or tablets of increasing diameter under fluoroscopy, in the upright position. Pills were given sequentially until a pill failed to traverse the esophagus in less than 20 s. The diameter of the pill failing to traverse the esophagus within 20 s correlated strongly with the endoscopically measured diameter by Spearmans rank correlation (Rs = 0.85). The weakest correlation was between endoscopically measured diameter and the dysphagia scale (Rs = 0.48). The diameter of the pill failing to traverse the esophagus within 20 s is an excellent estimate of esophageal lumen diameter. Pill size correlates much better with esophageal lumen diameter than dysphagia or diet scales. This new dysphagia assessment system should simplify standardization of the grading of dysphagia.

In a multicenter pilot study, a prototype bipolar electrocoagulation tumor probe was employed for palliation of obstructing circumferential esophageal cancer in 20 patients. Mean number of initial treatment sessions was 1.7. Dysphagia and tumor channel size improved significantly after treatment. Mean treatment interval before repeat treatment was 7.6 weeks. Major complications included delayed hemorrhage (two patients) and esophageal-pulmonary fistula (two patients). This new device may provide a less expensive alternative to laser or surgery for palliation of malignant esophageal obstruction.

Pancreatic abscess is an uncommon but often catastrophic complication of acute pancreatitis. This study reviews the past 10 yr experience at the University of South Florida Teaching Hospitals involving patients diagnosed to have pancreatic abscess. The etiology, management, complications, and factors affecting mortality are discussed. The results indicate: the presentation of pancreatic abscess is variable; increased positive prognostic signs (by Ranson's criteria) on initial presentation correlate with increased mortality; complications are common (80%) and contribute significantly to morbidity and mortality; CT scan is more accurate than ultrasound in the diagnosis of pancreatic abscess; poorly localized phlegmonous pancreatic slough noted by CT scan, sonography, or exploratory laparotomy, carries a higher mortality than a well-localized purulent collection; negative blood cultures or abscess cultures do not rule out pancreatic abscess; infection of lesser sac fluid collections can occur in the hospital implying that strict attention must be paid to nosocomial infections; the timing of surgical drainage is critical, recurrent abscess requires repeat surgery, and resection is associated with a very high mortality (reflecting greater severity of underlying disease); there has been no change in mortality of pancreatic abscess in the last 10 yr.

An otherwise healthy 28-year-old quadriplegic patient was admitted to the hospital with a core temperature of 76 degrees F secondary to accidental hypothermia. Her neurologic disability was detrimental to thermoregulation by decreasing her ability to shiver actively and to vasoconstrict. The relationship between shivering and thermoregulation is discussed.

Many authors have objected to the use of esophageal stents in the palliative management of lesions obstructing the cervical esophagus, especially when the prosthesis must lie within 2 cm of the cricopharyngeus muscle (CPM). Ten patients with stenosis of the cervical esophagus by lesions within 2 cm of or involving the CPM were considered for prosthesis placement. The prosthesis was successfully placed in eight patients, five of whom had a tracheoesophageal fistula (TEF). A prosthesis could not be placed in two patients, and two patients complained of a minimal but tolerable foreign body sensation. Six prostheses were custom-made. The necessity to place a prosthesis within 2 cm of or even immediately proximal to the CPM should not be considered an absolute contraindication to esophageal prosthesis placement in selected patients. Foreign body sensation may be absent or minimal, and stent migration is common.

Five cases of granular cell tumor of the esophagus are reported. In four cases, the tumor was an asymptomatic, incidental finding. In one case, a larger granular cell tumor presented with dysphagia and required local surgical excision. Long-term follow-up in three cases revealed no evidence of tumor progression. Esophageal granular cell tumors are benign lesions which can frequently be diagnosed by endoscopic biopsy. Asymptomatic, smaller lesions require observation only. Larger, symptomatic lesions can be treated with local surgical excision.

Over the past ten years, 21 cases of pancreatic abscess were diagnosed at our university teaching hospital. On the basis of the findings from CT scan, sonography, and exploratory laparotomy, five patients were determined to have poorly localized disease and 16 patients were felt to have well localized purulent fluid collection. The five patients with poorly localized disease had an overall mortality rate of 80%, an average of 5.2 Ranson criteria, and 80% required partial pancreatic resection. Of the 16 patients with well localized disease there was a mortality rate of 20%, an average of 3.3 Ranson criteria, and only 6% required resection. All five patients who had pancreatic resection died. These data suggest the following conclusions: 1. Patients with pancreatic abscess which is poorly localized have a greater severity of pancreatitis as indicated by a higher average number of Ranson criteria. 2. Patients with a poorly localized phlegmonous abscess more often require pancreatic resection, which is associated with a higher mortality. 3. The high mortality rate seen with patients with a poorly localized phlegmonous pancreatic slough designates this group as a high risk subset of all pancreatic abscess patients.