Endoscopic submucosal dissection in dogs in a World Gastroenterology Organisation training center

AIM: To evaluate if canine models are appropriate for teaching endoscopy fellows the techniques of endoscopic submucosal dissection (ESD).

METHODS: ESD was performed in 10 canine models under general anesthesia, on artificial lesions of the esophagus or stomach marked with coagulation points. After ESD, each canine model was euthanized and surgical resection of the esophagus or stomach was carried out according to “The Principles of Humane Experimental Technique, Russel and Burch”. The ESD specimens were fixed with needles on cork submerged in a formol solution with the esophagus or stomach, and delivered to the pathology department to be analyzed.

RESULTS: ESD was completed without complications using the Hook-knife in five esophageal areas, with a procedural duration of 124 ± 19 min, a length of 27.4 ± 2.6 mm and a width of 21 ± 2.4 mm. ESD was also completed without complications using the IT-knife2 in five gastric areas, with a procedural duration of 92.6 ± 19 min, a length of 32 ± 2.5 mm and a width of 18 ± 3.7 mm.

CONCLUSION: ESD is feasible in the normal esophagus and stomach of canine models, which are appropriate for teaching this technique.

SECCA procedure for the treatment of fecal incontinence: results of five-year follow-up

PURPOSE

This study evaluated the long-term (5-year) durability of radiofrequency energy delivery for fecal incontinence.

METHODS

This was an extension of the follow-up from our original prospective study in which patients who suffered from fecal incontinence were treated with the SECCA system for radiofrequency energy delivery to the anal canal muscle. The Cleveland Clinic Florida Fecal Incontinence Scale (0-20), fecal incontinence-related quality of life score, and Medical Outcomes Study Short-Form 36 were administered to five years. Differences between baseline and follow-up were analyzed by using paired t-test.

RESULTS

A total of 19 patients were treated and followed for five years, including 18 females (aged 57.1 (range, 44-77) years). The mean duration for fecal incontinence was 7.1 (range, 1-21) years. At five-year follow-up, the mean fecal incontinence score had improved from 14.37 to 8.26 (P<0.00025) with 16 patients (84.2 percent) demonstrating>50 percent improvement. All fecal incontinence-related quality of life scores improved, including lifestyle (2.43 to 3.15; P<0.00075), coping (1.73 to 2.6; P<0.00083), depression (2.24 to 3.15; P<0.0002), and embarrassment (1.56 to 2.51; P<0.0003). The social function component of the Short-Form 36 improved from 38.3 to 60 (P<0.05). There was a trend toward improvement in the mental component summary of the Short-Form 36 from 38.1 to 48.14. There were no long-term complications.

CONCLUSIONS

Significant and sustained improvements in fecal incontinence symptoms and quality of life are seen at five years after treatment with the SECCA system. This treatment should be considered for patients suffering from fecal incontinence not amenable to surgery and who have failed conservative management.

Performance, tolerability, and symptoms related to prolonged pH monitoring using the Bravo system in Mexico

BACKGROUND

The traditional system for esophageal 24-h pH monitoring requires transnasal introduction of the catheter with pH sensors; this technique produces discomfort, inconvenience, and interference with daily activity. Recently, a catheter-free pH monitoring system (Bravo) has been proposed as an alternative and promising method for 24-h pH.

AIM

To evaluate performance, tolerability, and symptoms related to this new technology in our population.

METHODS

Consecutive patients with gastroesophageal reflux disease (GERD) with indication for 24-h pH were included. pH Bravo capsule was placed 6 cm above the squamocolumnar junction using endoscopic measurement. Symptoms associated were evaluated daily in a personal diary until 7 days after the capsule attachment. Severity of symptoms was assessed by a 5-point Likert scale. Capsule detachment was assessed by chest X-ray.

RESULTS

Eighty-four patients were included. Forty-nine were female (mean age 44 +/- 12 yr). Indications for pH monitoring were: nonresponse to proton pump inhibitor therapy in 38 (45%), preoperative evaluation for anti-reflux surgery in 36 (43%), previous failed transnasal 24-h pH monitoring in 6 (7%), and extra-esophageal manifestations of GERD in 4 (5%). The capsule was successfully attached in 95% of patients. At day 7, capsule detachment occurred spontaneously in all cases. Symptoms related to capsule attachment were: chest pain in 26 (33%), foreign body sensation in 11 (14%), nausea in 5 (6%), and 9 (11%) patients had more than one symptom. Severities of those symptoms were mild, and no patient required removal of the capsule. Women and younger patients had more symptoms related to the procedure (p < 0.05).

CONCLUSIONS

Esophageal pH monitoring with Bravo capsule is a safe, reliable, and tolerable method in patients with GERD.

Laparoscopic Heller myotomy for classic achalasia: results of our initial series of 20 patients

BACKGROUND

The aim of this study was to review our results in the surgical management of achalasia by laparoscopic esophageal cardiomyotomy and partial fundoplication.

METHODS

The patient population was comprised of a consecutive series of 20 patients with classic achalasia who underwent laparoscopic cardiomyotomy and partial fundoplication. Clinical, radiological, and physiological characteristics were analyzed prospectively, with an emphasis on the outcome and complications.

RESULTS

There were 12 women and eight men; their mean age was 37 years. Four intraoperative complications occurred-two mucosal perforations that were resolved laparoscopically and two cases of pneumothorax. The median hospital stay was 4 days (range, 2-14) and the median time to start oral feeding was 3 days (range, 1-7). After a median follow-up of 14 months (range, 2-83), 16 patients were asymptomatic and four had mild heartburn and/or dysphagia. All patients gained weight (median, 8.0 kg; range, 1-23). We observed a median postoperative decrease in esophageal diameter of 1.6 cm (range, 0.2-2.9). Fifteen patients were subjected to physiological esophageal studies; the results showed that power esophageal sphincter pressure had decreased from 32 (range, 15-60) to 12 mmHg (range, 6-25). The median DeMeester score was 14.5 (range, 0.9-194). The median esophageal acid exposure was 3% (range 0-34.6).

CONCLUSIONS

Our initial experience with the laparoscopic management of classic achalasia yielded satisfactory clinical, radiological, and physiological results.

Etiology of liver cirrhosis in Mexico

BACKGROUND

In the last decades it has been suggested that the main cause of liver cirrhosis in Mexico is alcohol. Currently in Western countries hepatitis C virus stage liver disease and liver transplantation. In Mexico, we have no data relative to the etiology of liver cirrhosis. The aim of this study was to investigate the main causes of liver cirrhosis in Mexico.

METHODS

Eight hospitals located in different areas of the country were invited to participate in this study. Those hospitals provide health care to different social classes of the country. The inclusion criteria were the presence of either an histological or a clinical and biochemical diagnosis of liver cirrhosis.

RESULTS

A total 1,486 cases were included in this study. The etiology of liver cirrhosis was alcohol in 587 (39.5%), HCV 544 (36.6%), cryptogenic 154 (10.4%), PBC 84 (5.7%), HBV 75 (5.0%) and other 42 (2.8%). There was no statistical difference between alcohol and HCV.

CONCLUSIONS

We conclude that the main causes of liver cirrhosis in Mexico are alcohol and HCV.

A rare case of multiple lymphomatous polyposis with widespread involvement of the gastrointestinal tract

Multiple lymphomatous polyposis (MLP) is an uncommon type of primary non-Hodgkin gastrointestinal (GI) B-cell lymphoma characterized by the presence of multiple polyps along the GI tract. Malignant cells of MLP have mantle cell characteristics and thus are considered to be the counterpart of the mantle cell lymphoma (MCL) in the GI tract. Since 1961, no more than 70 well-documented cases have been published. We report the case of 53-year-old man diagnosed as having MLP. The patient presented with diffuse abdominal pain, chronic lower GI bleeding, peripheral lymphadenopathy, and weight loss. The lymphomatous polyps extended from the esophagus to the rectum, with bone marrow infiltration. Immunohistologic findings were characteristic of MCL. The patient was treated with a combined cyclophosphamide, vincristine, and prednisone chemotherapy regimen, resulting in a partial response.

A rare case of multiple lymphomatous polyposis with widespread involvement of the gastrointestinal tract

Multiple lymphomatous polyposis (MLP) is an uncommon type of primary non-Hodgkin gastrointestinal (GI) B-cell lymphoma characterized by the presence of multiple polyps along the GI tract. Malignant cells of MLP have mantle cell characteristics and thus are considered to be the counterpart of the mantle cell lymphoma (MCL) in the GI tract. Since 1961, no more than 70 well-documented cases have been published. We report the case of 53-year-old man diagnosed as having MLP. The patient presented with diffuse abdominal pain, chronic lower GI bleeding, peripheral lymphadenopathy, and weight loss. The lymphomatous polyps extended from the esophagus to the rectum, with bone marrow infiltration. Immunohistologic findings were characteristic of MCL. The patient was treated with a combined cyclophosphamide, vincristine, and prednisone chemotherapy regimen, resulting in a partial response.

Extended two-year results of radio-frequency energy delivery for the treatment of fecal incontinence (the Secca procedure)

PURPOSE

This study evaluated the durability and long-term safety of radio-frequency energy delivery for fecal incontinence (Secca procedure).

METHODS

This was an extended follow-up of a prospective study in which patients with fecal incontinence of various causes underwent radio-frequency energy delivery to the anal canal muscle. The Cleveland Clinic Florida Fecal Incontinence Scale (0-20), fecal incontinence-related quality-of-life score, and Medical Outcomes Study Short Form 36 were administered at baseline and at 1, 2, 3, 6, 12, and 24 months after the procedure. Differences between baseline and follow-up were analyzed with the Wilcoxon signed-rank test.

RESULTS

Ten females (aged 55.9 +/- 9.2 (range, 44-74) years) were treated. At two-year follow-up, the mean Cleveland Clinic Florida Fecal Incontinence Scale score was improved from 13.8 to 7.3 (P = 0.002), with eight patients having scores of < or =10. All fecal incontinence-related quality-of-life score parameters were improved, including lifestyle (from 2.3 to 3.3; P = 0.002), coping (from 1.7 to 2.7; P = 0.002), depression (from 2.4 to 3.4; P = 0.004), and embarrassment (from 1.5 to 2.4; P = 0.008). There was no decrement in effect noted in any parameter between 12 and 24 months (P > 0.2). The social function component of the Short Form 36 improved from 50 to 82.5 (P = 0.04), whereas there was an improvement trend for the mental component summary of the Short Form 36 from 38.3 to 48.1 (P = 0.11). Protective pad use was eliminated in four of the seven baseline users. There were no long-term complications, such as stricture, pain, or constipation.

CONCLUSIONS

A significant improvement in symptoms of fecal incontinence and quality of life persists two years after radio-frequency delivery to the anal canal, which demonstrates durability of this intervention.

[Ineffective motility in lower third of esophagus. Length of involved esophagus and severity of gastroesophageal reflux disease]

Ineffective esophageal motility (IEM) has been described in patients with gastroesophageal reflux disease (GERD). Exact prevalence of IEM is unknown; however, it is associated with more severe forms of GERD. There are no studies of IEM in patients with non-erosive GERD (NERD). Traditionally, IEM is identified by manometry at 3 and 8 cm above lower esophageal sphincter. Studies evaluating each cm of distal third of esophagus to detect IEM have not been carried out to date.

AIM

To determine frequency of an IEM in NERD and erosive GERD as well as in mild and severe esophagitis, and to compare traditional criteria of IEM vs. manometry of each cm of distal third of esophagus.

MATERIAL AND METHODS

Healthy controls and patients with NERD and mild and severe esophagitis were studied. Manometry of each cm of lower third of esophagus was performed. Amplitude of esophageal contractions and frequency of IEM were compared between different groups of subjects and patients. The ability to detect IEM by traditional criteria and proposed criteria was determined.

RESULTS

Forty-four subjects were included, 13 controls, 10 patients with NERD, 12 with mild esophagitis, and nine with severe esophagitis. Amplitude of contractions was significantly different between groups. Controls showed higher amplitude than patients with severe esophagitis. Frequency of IEM was 0% in controls, 20% in NERD, 17% in mild esophagitis, and 33% in severe esophagitis. Frequency of IEM was similar when traditional criteria and proposed criteria were compared.

CONCLUSIONS

IEM occurs in NERD as well as in mild and severe esophagitis, and IEM is associated with GERD severity. Traditional manometry detects similar proportion of patients with IEM as well as manometry of each cm of lower third of esophagus.

Irritable bowel syndrome in Mexico

The current review includes all the available original data on irritable bowel syndrome in Mexico. Data were organized in items of interest such as prevalence and gender distribution, health care utilization, psychosocial factors, diagnostic criteria, bowel habit predominance, physiological studies, clinical trials and quality of life assessment. After a systematic review, a total of 18 papers were included, the majority published between 1996 and 2000. We can conclude that irritable bowel syndrome in Mexico is similar to that reported in the international literature with regard to the areas analyzed, and therefore it is suitable to run clinical trials with similar outcomes as has been done in other populations.

Management of choledocholithiasis found during laparoscopic cholecystectomy: a strategy based on the use of postoperative endoscopic retrograde cholangiography and sphincterotomy

BACKGROUND

Several strategies have been proposed for the diagnosis and management of common bile duct stones in candidates for laparoscopic cholecystectomy.

METHODS

Clinical characteristics, treatment, and outcome of five patients in whom CBDS were demonstrated by intraoperative cholangiography during a laparoscopic cholecystectomy were analyzed. All patients were treated by endoscopic sphincterotomy. Post-treatment outcome was emphasized.

RESULTS

Mean age of the patients was 55 years. Four were female and one male. Preoperative liver function tests were within normal range in all patients. Duct stones of a mean size of 0.8 cm were found in the lower third of the biliary tree. Four were retrieved by endoscopic sphincteroplasty using a Dormia basket and in one patient after an unsuccessful endoscopic attempt, an open choledochoduodenostomy was performed. There were no post-treatment complications. At a mean follow-up of 2 years no evidence of recurrent common bile duct obstruction has been found in any patient.

CONCLUSIONS

This small series supports the use of postoperative endoscopic retrograde cholangiography and sphincteroplasty in patients with unsuspected common bile duct stones found during laparoscopic cholecystectomy. Retrieval of the stones immediately after surgery at the operative room is recommended.

[Hirschsprung disease in the adult. Report of a case]

OBJECTIVE

To describe a case of Hirschsprung's disease (HD) in an adult patient.

BACKGROUND

HD is diagnosed in the newborn in 80 to 90% of cases. HD is rare in the adult, and usually affects an ultrashort segment of the bowel.

CASE REPORT

A 49-year-old woman with a history of constipation since birth is involved. She was submitted to an abdominal laparotomy because of fecal impaction. A colostomy was performed. The diagnosis of HD affecting, the descending colon was established with manometry and histopathology. She underwent surgery, and a proctectomy and left hemicolectomy with colo-anal anastomosis was performed.

CONCLUSION

Adult HD is an infrequently diagnosed entity that must be suspected in a patient with chronic, intractable constipation from infancy, evidence of megacolon, and typical manometric and histopathologic features. The short and ultrashort-segment disease are more often found in older children and adults. The differential diagnosis includes idiopathic megarectum, functional constipation, and colonic pseudo-obstruction.

[Case and control study of atypical manifestations in gastroesophageal reflux disease]

OBJECTIVE

To study the prevalence of atypical symptoms of gastroesophageal reflux disease (GERD) in patients with esophagitis compared to controls.

METHODS

We studied consecutive patients who underwent upper endoscopy between January and August of 1997. They were classified in two groups: a) Cases, patients with endoscopic diagnosis of reflux esophagitis, and b) Controls, patients without esophagitis nor typical symptoms of GERD. They answered a questionnaire to evaluate the presence of typical and atypical symptoms of GERD.

RESULTS

There were 50 cases and 50 controls. There were no intergroups differences related to gender (p = 0.2), age (p = 0.4), smoking history (p = 0.7) or history of allergic diseases (p = 0.6). The atypical symptoms of GERD were more frequent in cases (66%) than controls (42%) (OR = 2.7%, 95% CI = 1.2-6, p = 0.02). The atypical manifestations more frequent in the cases were hoarseness (OR = 9.3, CI 1.1-77), thoracic pain (4.9, 1.7-14) and globus (2.8, 0.9-9). The presence of atypical symptoms was not associated to the degree of esophagitis (p = 0.7), intensity of typical symptoms (p = 0.2), gender (0.4) or age of patients (p = 0.2).

CONCLUSION

Patients with reflux esophagitis have a higher risk to develop extraesophageal disorders of the pharynx, larynx and lungs.

Reduced accuracy of 14C-D-xylose breath test for detecting bacterial overgrowth in gastrointestinal motility disorders

The accuracy of the 14C-D-xylose breath test in the diagnosis of small-bowel bacterial overgrowth was prospectively evaluated in 10 patients with motility disorders: 6 myopathic, 3 neuropathic, and 1 mechanical obstruction. Six of the 10 patients had small-bowel bacterial overgrowth (> or = 10(5) colony-forming units/ml) on culture of small-bowel aspirate. Increased breath 14CO2 levels were documented in three of six patients with positive cultures and in two of four with negative cultures. Two patients with positive results by both methods and one of two patients with positive breath 14CO2 but negative cultures had previously undergone gastric surgery. Three patients with myopathic dysmotility had positive cultures but negative breath tests. Cultures of duodenal aspirates and the D-xylose test had sensitivities of 80% and 40%, respectively, for the finding of hypoalbuminemia. Compared with cultures, the sensitivity and specificity of the breath test were 60% and 40%, respectively. Impaired delivery of 14C-D-xylose for bacterial metabolism may result from postprandial antral hypomotility (n = 4) or low-amplitude (n = 6) small-bowel motility, contributing to the false-negative breath tests. Thus, culture is the optimal method to detect small-bowel bacterial overgrowth in patients with motility disorders.

Chronic diarrhea in diabetes mellitus: mechanisms and an approach to diagnosis and treatment

In this study, our aim was to develop a practical strategy to facilitate the management of patients with diabetes mellitus and chronic diarrhea in a tertiary referral practice. We reviewed the pertinent English-language literature of the past 30 years that described the pathophysiologic mechanisms and treatment of patients with diabetic diarrhea and retrospectively reviewed the medical records of all patients with diabetic diarrhea examined at the Mayo Clinic during 1990. Three typical case studies are described to illustrate the diverse mechanisms that lead to chronic diarrhea in patients with diabetes. No report in the literature has systematically evaluated all the putative mechanisms of chronic diarrhea in any group of patients with diabetes. In our tertiary referral practice, diabetic diarrhea was frequently due to celiac sprue, bacterial overgrowth in the small bowel, or fecal incontinence in conjunction with anorectal dysfunction; however, in almost 50% of the patients, these causes were excluded, and abnormal intestinal motility or secretion was postulated to be one of the likely causes of the diarrhea. These data suggest a practical algorithm based on three sequential assessments: first, tests of blood and stool specimens and flexible sigmoidoscopy to detect evidence of malabsorption or disease in the distal colon; second, small bowel aspirate and biopsy if the results of initial blood or stool tests are abnormal or anorectal function tests if those test results are normal; and, finally, measurement of gastrointestinal transit or therapeutic trials with opioids, clonidine hydrochloride, and, rarely, cholestyramine resin or octreotide acetate (or both methods). The mechanisms whereby abnormal neural function due to diabetes results in altered digestive, secretory, absorptive, or motor function necessitate further elucidation. The management of chronic diarrhea in patients in a tertiary referral practice, however, can be based on a practical algorithm to determine the cause and to adopt specific treatment to correct it.

Effects of serotonin on rat ileocolonic transit and fluid transfer in vivo: possible mechanisms of action

The aim was to investigate the action of serotonin (5HT) on function of the ileocolonic junction (ICJ) in vivo. In anaesthetised rats, models were developed to study the effects of intra-aortic (ia) serotonin on ileocolonic and colonic transit, and the effects on transit of a number of 5HT receptor antagonists. In the first series of experiments, a bolus of saline labelled with 99mTc DTPA was instilled 20 cm proximal to the ICJ and transit was assessed three hours later by the geometric centre of the spread of isotope. In the second series, similar techniques were used on the postcaecal colon and transit assessed two hours later. In the third series of experiments, the effects of ia 5HT on ileal net fluid flux was evaluated by standard perfusion experiments with 14C polyethylene glycol (PEG) 4000 as a non-absorbable marker in rat plasma-like electrolyte solution. Compared with ia saline, 5HT accelerated ICJ transit significantly (p < 0.05). This acceleration was comparable with the effect of ia bethanechol. The effects of 5HT on ICJ transit were inhibited by the intraperitoneal (ip) infusion of atropine, the 5HT receptor antagonists, methysergide, ketanserin, zacopride, and the 5HT4 agonist, SC53116. Methysergide, zacopride, and SC53116 given with ia 5HT slowed ICJ transit to rates below those of ia saline alone. When these same agents were given together with ia saline, the ICJ transit was not significantly altered. Serotonin, at the dose that accelerated ICJ transit, did not significantly alter colonic transit or ileal fluid transport. In conclusion, 5HT is a potent pharmacological stimulant of transit across the rat ICJ in vivo; the action of 5HT is mediated partly through muscarinic neurones and several 5HT receptor subtypes.

Effect of putative carcinoid mediators on gastric and small bowel transit in rats and the role of 5-HT receptors

Whereas serotonin and substance P stimulate in-vivo and in-vitro myoelectric activity in the small intestine, their effects on transit are unclear. We used a validated in-vivo transit model in the chloral hydrate-anaesthetized rat to study the effects of serotonin, substance P and motilin, three putative mediators of carcinoid diarrhoea, on transit through the upper digestive tract. Intra-arterial serotonin accelerated gastric emptying of a radiolabelled liquid, while motilin accelerated overall upper gastrointestinal transit. Substance P slowed overall upper gastrointestinal transit without altering gastric emptying. The antagonists to serotonin receptor subtypes, R-zacopride (5-HT3) and ketanserin (5-HT2), also accelerated rat gastric emptying of liquids; in contrast, a 5-HT4 agonist, SC53116, resulted in a less pronounced effect on gastric emptying at the dose tested. We conclude that circulating substance P is unlikely to be an important accelerator of transit through the upper digestive tract; in contrast, hyperserotoninaemia significantly accelerates transit through the stomach, and 5-HT2 and 5-HT3 receptor subtypes may play a role in the motor effects of serotonin in the stomach.

Anorectal dysfunction and rectal prolapse in progressive systemic sclerosis

Our aim was to characterize the clinical spectrum of anorectal dysfunction among eight patients with progressive systemic sclerosis (PSS) who presented with altered bowel movements with or without fecal incontinence. The anorectum was assessed by physical examination, proctosigmoidoscopy, and anorectal manometry. There was concomitant involvement of the other regions of the digestive tract in all patients as determined by barium studies, endoscopy, or manometry: eight esophageal, three gastric, four small bowel, and two colonic. Seven patients had fecal incontinence, and four also had second-degree complete rectal prolapse. Abnormal anorectal function, particularly abnormal anal sphincter resting pressures, were detected in all patients; anal sphincter pressures were lower in those with rectal prolapse. Rectal capacity and wall compliance were impaired in seven of seven patients. Successful surgical correction of prolapse in three patients resulted in restoration of incontinence for six months and seven years in two of the three patients. We conclude that rectal dysfunction and weakness of the anal sphincters are important factors contributing, respectively, to altered bowel movements and fecal incontinence in patients with gastrointestinal involvement by PSS. Rectal prolapse worsens anal sphincter dysfunction and should be sought routinely as it is a treatable factor aggravating fecal incontinence in patients with PSS.

[Electrolyte solution with polyethylene glycol to cleanse the colon for colonoscopy or enema]

The efficacy and safety of an electrolyte-polyethylene glycol solution (SE-PEG) for colonic lavage, was compared with standard bowel preparation (SBP) in a randomized blinded study of volunteers and patients undergoing colonoscopy and barium enema examination. Side effects, biochemical and hematologic changes and quality of examinations were monitored. Colonoscopy and barium enema was scored by colonic segment for type of residual stool and percentage of bowel wall visualized. For colonoscopy and barium enema, preparation with SE-PEG allowed better visualization and produced more optimal exams (8 vs 3; p less than 0.03) and (6 vs 4; p = NS) respectively. We conclude that colonic lavage with SE-PEG is an alternative bowel preparation method and is cheaper, more safe and effective than SBP procedure.

[Retrospective evaluation of 500 endoscopic cholangiopancreatographies performed at the Instituto Nacional de la Nutrición "Salvador Zubiran"]

We evaluated 500 endoscopic retrograde cholangiopancreatographies (ERCP) performed on 422 patients during a 5-year period in the Gastrointestinal Endoscopy Department, Instituto Nacional de la Nutrición Salvador Zubirán, México, D.F. ERCP combines endoscopic and radiologic techniques in order to obtain high quality opacification of pancreatic and biliary ducts. The rate of success for cannulation was 90%; desired duct opacification was possible in 89%. The most frequent indication for ERCP was to establish the differential diagnosis for jaundice; biliary stones in the common bile duct was the most frequent diagnosis, followed by normal biliary ducts. Pancreatography was normal in 74% of patients. ERCP complications were detected in 5.6%; fever and transient pain was the most common complaint in 1.6%. Mortality attributable to the procedure was 0.8%. From histological corroboration of cases by surgery or postmortem studies, diagnostic sensitivity was 92%, specificity 76%, positive predictive value 96% and a prevalence of 89%. We conclude that ERCP is highly sensitive and specific in diagnosing bilio-pancreatic-duodenal disease. Our results are comparable to other's experiences published throughout the world.