Upper gastrointestinal endoscopy after cardiac transplantation

Three hundred four patients have undergone cardiac transplantation at the University of Pittsburgh since 1980. Twenty patients have required 27 upper gastrointestinal (GI) endoscopic procedures. After heart transplantation the primary indications for endoscopy were epigastric pain (six patients with gastritis, one with multiple shallow gastric ulcers, and one with normal test results), mild upper GI bleeding (four patients with esophagitis, two with gastritis, and two with multiple shallow gastric ulcers), dysphagia and odynophagia (two patients with esophagitis), persistent nausea and vomiting (one with normal test results), lower GI bleeding (one with normal test results), and routine follow-up (one with normal test results). After heart-lung transplantation the primary indications for the endoscopy were massive upper GI bleeding (three patients with actively bleeding duodenal ulcers), dysphagia and odynophagia (one patient with esophagitis), mild upper GI bleeding (one patient with gastritis), and routine follow-up (one patient with normal test results). No complications resulted from endoscopy. The procedures were performed in the GI suite without cardiac monitoring. Prophylactic antibiotics were not routinely administered. No patient had a fungal infection of the upper GI tract--a finding attributed to the prophylactic use of nystatin in all patients. Opportunistic viral infections were identified histologically in six patients, including two patients with actively bleeding duodenal ulcers. The possibility of opportunistic viral infections in this immunosuppressed group required aggressive diagnostic techniques, including endoscopy and biopsy, which can be safely performed after cardiac transplantation.

Endoscopy in peptic diseases and bleeding: a community survey of 1635 patients

Panendoscopy was analysed prospectively on 1635 patients in a personal series for the years 1976 to 1979, under standard conditions, including for emergency bleeding. 48% of males showed lesions, compared with 38% of females. Important diseases were uncommon under 40 years of age, except for reflux disease of the oesophagus. Duodenal ulcer craters exceeded gastric ulcers in the ratio of 1.6 to 1.0. The 103 chronic gastric ulcers were analysed according to gender (male to female ratio 1.6 to 1.0), age (only 4% were seen under the age of 40), diameter and location (larger ulcers were more common in the body of the stomach than the antrum). Multiple gastric ulcers occurred in 9 patients, while pyloroduodenal ulcers coexisted with gastric ulcer in 7. Duodenal ulcers seen in 164 patients were multiple in 12; only 4% occurred under 30 years of age. The duodenal ulcer male to female ratio for Europeans was 2.5 to 1.0. Cancer of the stomach was uncommon (36 patients). Reflux oesophageal disease (182 patients) was the most common disorder diagnosed endoscopically. The commonest lesions found in acute bleeding (174 patients) were duodenal ulcer in 19%, gastric ulcer in 11%, oesophageal erosions 17% and gastroduodenal erosions in 17%.

Diagnostic evaluation: gastric acid secretion and pH

The diagnostic value of gastric secretion tests has been found to be lower than what was previously believed. Thus basal and stimulated acid output is normal in most ulcer patients, and this is also so for gastric and duodenal pH. Gastric acid secretion does not separate patients with rapid recurrence after medical treatment from those with a long period of remission, and acid secretion is usually not higher in patients with recurrence after vagotomy than in patients without relapse. Today a gastric acid secretion test is used in patients suspected of the Zollinger-Ellison syndrome and it seems also to be valuable in ulcer patients who do not respond clinically satisfactory to medical treatment.

Dyspepsia. The broad etiologic spectrum

Dyspepsia remains one of mankind's most common afflictions. It affects virtually everybody at one time or another, it is responsible for the hundreds of millions of dollars spent each year on antacids and H2 antagonists, and it ranks second only to the common cold as a cause of loss of time from work. The condition denotes widely different things to different people, but by definition, complaints of dyspepsia must bear some relation to food or drink. (The term "dyspepsia" derives from dys, meaning "bad," and pepsis, meaning "digestion.") A physician writing in the Lancet more than a hundred years ago referred to dyspepsia as "the remorse of a guilty stomach." Unfortunately, the problem often turns out to be more serious than the transient pangs emanating from overindulgence. "Dyspepsy," De Quincey wrote in 1823, "is the ruin of most things: empires, expeditions, and everything else." That may be an overstatement. Still, dyspepsia can certainly be the harbinger of disastrous illness, as the following case illustrates.

Gastroduodenal mucosal hemodynamics by endoscopic reflectance spectrophotometry

The reflectance spectrophotometric technique measures an index of mucosal hemoglobin concentration and an index of oxygen saturation by spectral analysis of light reflected from the mucosal surface. Using a commercially available unit, a technique for obtaining reproducible endoscopic measurements with acceptable intraobserver and interobserver variability was developed in the anesthetized dogs. The reflectance spectrophotometric finding that experimentally induced prehepatic portal hypertension did not affect gastric mucosal blood flow was confirmed by hydrogen gas clearance measurements. Endoscopic studies in patients with active duodenal ulcer disease revealed a higher index of mucosal hemoglobin concentration and a normal index of oxygen saturation (i.e., an increase in blood flow) at the margin of the ulcer compared with the adjacent normal appearing mucosa.

Duodenal ulceration: review of 110 cases

This paper describes 110 cases of childhood duodenal ulcer, which were diagnosed over 26 years: 63 were diagnosed by barium meal examination; 47 by upper gastrointestinal endoscopy. The mean age at diagnosis was 11.2 years, with symptoms reported in 46% before 10 years and in 15% before 6 years of age. There was often a considerable delay in diagnosis, particularly in the younger age group. Nocturnal pain (61%) and a close family history of duodenal ulcer disease (62%) were the most valuable pointers to the diagnosis. Fifteen children had required surgery for persistent symptoms. Thirty four had received treatment with an H2 receptor antagonist, and all but four had had a satisfactory initial response. Seventy per cent relapsed within six months of discontinuing treatment, and long term maintenance treatment may therefore be necessary.

Do symptoms of gastric ulcer become less frequent with time?

It has been claimed that gastric and duodenal ulcer (GU and DU) symptoms decrease in frequency with time, indicating 'burn out' of ulcer. The present study was undertaken to investigate further this phenomenon in GU. The prevalence of symptom experience during 1 year was examined in 447 medically treated patients with GU diagnosed 2-20 or more years previously. When ulcer history length was measured from either first symptom onset or first ulcer diagnosis, reporting of symptoms did not become less frequent as history length increased. This remained true after adjustment for GU location, sex, age, smoking, and analgesic and non-steroidal anti-inflammatory drug ingestion. It is concluded that GU symptoms do not decrease in frequency with time.

[Behavior in disability assessment of uncomplicated duodenal ulcer--a study]

There is internationally no standardized therapy of the uncomplicated duodenal ulcer, including the inability to work. In order to obtain a representative behaviour concerning the duration of the inability to work prescribed by specialists for general medicine, internal medicine and surgery, an interrogation was performed. An evaluation of 729 questionnaires shows the following tendency: 1. The younger the attending physician is the longer is the time of inability to work prescribed and the more frequent such a certificate is given. 2. General practitioners in rural districts on an average prescribe a longer time of inability to work. 3. The higher is the qualification of the specialist for internal medicine the shorter is the duration of inability to work attested. 4. In the assessment of the duration of the inability to work the attending physicians increasingly accommodate themselves rather to the symptoms than to the radiological or to the endoscopic control of healing.

Prognosis of chronic duodenal ulcer: a prospective study of the effects of demographic and environmental factors and ulcer healing

The aim of this prospective study of 370 community based duodenal ulcer patients was to define the effect on duodenal ulcer course (from the aspect of symptom occurrence) of demographic and environmental factors, and of proven healing of index ulcer within four months. Follow up was three monthly, for up to three years. By survival analysis, it was found that marriage breakup adversely affected duodenal ulcer course, that age 50 years and under, female sex, and aspirin use tended to do so, and that smoking, alcohol ingestion, and paracetamol use did not. Proven healing of index ulcer within four months was associated with a small and non-significant reduction in symptom occurrence over time.

Modified sham feeding test after parietal cell vagotomy for juxtapyloric ulcer disease in patients with and without recurrent ulcers

The mean of individual coefficients of variation of acid output after modified sham feeding was 39% in 22 patients operated on with parietal cell vagotomy. The reproducibility of the interpretation of the sham feeding test as 'positive' or 'negative' was good. An intragastric infusion of a marker to correct for pyloric loss did not increase the accuracy of the test. The prognostic value of the qualitative estimation of the sham feeding test 2 months after operation to predict recurrent ulcer after parietal cell vagotomy was poor in 39 patients studied prospectively over 3 years. With the criterion sham feeding minus basal acid output over 1.0 mmol/30 min as a positive test, 63% of patients with a positive and 24% with a negative test later had recurrent ulcers. The consistency of the interpretation as either positive or negative was low in annual tests during the 3 years of follow-up study. After parietal cell vagotomy the sham-feeding-stimulated acid output was higher in patients with duodenal than in those with prepyloric recurrent ulcers and also in those without recurrences. This indicates that the amount of vagal innervation left after parietal cell vagotomy is of special importance in the occurrence of duodenal ulcer relapse.

Choledochoduodenal fistula: a rare complication of peptic ulcer disease

Choledochoduodenal fistula is a rare complication of peptic ulcer disease. Many cases are asymptomatic and incidentally diagnosed. Treatment is controversial and ranges from medical treatment of peptic ulcer disease alone, to vagotomy with antrectomy or gastroenterostomy. Common bile duct exploration and reconstruction are reserved for cases with biliary stricture.