Complications of fiberoptic endoscopy

X-ray diagnosis of synchronous multiple primary carcinoma in the upper gastrointestinal tract

AIM: To analyze the radiological features of multiple primary carcinoma (MPC) in the upper gastrointestinal (GI) tract, study its biological characteristics and evaluate X-ray examination in its diagnosis.

METHODS: Hypotonic double-contrast GI radiography was performed in 59 multiple primary carcinoma cases, pathologically proved by surgery or endoscopy biopsy. Radiological findings were analyzed.

RESULTS: Of the 59 cases, esophageal MPC (EMPC) was seen in 24, esophageal and gastric MPC (EGMPC) in 27 and gastric MPC (GMPC) in 8. Of the 49 lesions found in 24 EMPC, hyperplastic type was seen in 23, medullary type in 9. The lesions were located at the upper (n = 17), middle (n = 19) or lower (n = 13) segment of the esophagus. In 27 EGMPC, the esophageal lesions were located at the middle (n = 16) or lower (n = 11) segment of the esophagus, while the gastric lesions were located at the gastric cardia (n = 16), fundus (n = 1), body (n = 3) and antrum (n = 7). The esophageal lesions were mainly of the hyperplastic type (n = 12) or medullary type (n = 7), while the gastric lesions were mainly of the hyperplastic type (n = 18). A total of 119 lesions in the 59 patients with synchronous multiple carcinoma were proved by surgery or endoscopy biopsy, and preoperative upper radiographic examination detected 100 of them (84.03% sensitivity). Eighteen (52.94%) of the T₁ lesions were found during preoperative diagnosis by radiographic examination. Moreover, only 3 (3.53%) of the T_2-4 lesions were misdiagnosed.

CONCLUSION: Hypotonic double-contrast upper gastrointestinal examination, providing accurate information about lesion morphology, location and size, can serve as a sensitive technique for the preoperative diagnosis of MPC.

[A case of acute myocardial infarction occurred immediately after endoscopic submucosal dissection]

Endoscopic methods such as endoscopic mucosal resection or endoscopic submucosal dissection (ESD) have been increasingly used for the treatment of gastric adenoma and early gastric cancer. Especially, ESD is very useful since it allows en bloc resection of large lesions. Bleeding and perforation are well known as common complications after ESD. However, there is no report of acute myocardial infarction associated with ESD. We report a case of acute myocardial infarction which was detected immediately after ESD.

Iatrogenic esophageal submucosal dissection after attempted diagnostic gastroscopy (with videos)

Diagnostic esophagogastroduodenoscopy (EGD) is generally a very safe procedure. We report the first case of iatrogenic esophageal submucosal dissection after an attempted diagnostic gastroscopy in a patient with a small previously undiagnosed Zenker's diverticulum (ZD). After EGD, she developed severe dysphagia with the inability to swallow solids, liquids, and even her own saliva. On barium swallow study, there was a column of contrast below the upper esophageal sphincter, and this was misdiagnosed as a large ZD by the radiologist. The resultant stricture was successfully managed with endoscopic balloon dilatation under fluoroscopy with wire-guided cannulation. The ZD was treated with flexible endoscopic clip-assisted diverticulotomy. Iatrogenic submucosal dissection is a unique complication of upper endoscopy. Endoscopists, otolaryngologists, radiologists, and cardiothoracic surgeons should be aware of this condition and prepare to manage it appropriately. If the patient is stable and the possibility of perforation is small, conservative and supportive care can be tried first. A surgical gastrostomy tube can be placed for enteral feeding. In patients with ZD, ZD recognition and gentle manipulation is strongly recommended during esophageal intubation.

Quality of patient referral information for open-access endoscopic procedures

BACKGROUND

Increased demand for endoscopic procedures has led to the provision of these services without prior consultation (open access). The need for accurate medical referral information for these patients is vital for patient safety.

OBJECTIVE

To assess the accuracy of endoscopic referral information.

DESIGN

Over a 4-month study period, patient referral forms were evaluated to determine the accuracy of medical information on patient referral forms by using direct interview with the patient and/or the caregiver. Inconsistencies were validated against medical records.

SETTING

Large academic medical clinic.

PATIENTS

A total of 868 open-access patient referrals for upper endoscopy and colonoscopy services.

MAIN OUTCOME MEASUREMENTS

Referral information about medical diagnoses, medications, allergies, need for antibiotic administration, and current coagulopathies.

RESULTS

Inaccurate medical referral information was provided to the endoscopist in 8.8% of referrals (n = 76). Among referrals containing errors, there were a total of 95 significant medical information errors, which, if left undetected by preprocedure review, could have resulted in serious adverse consequences for patients undergoing endoscopy.

LIMITATIONS

Study limited to an academic clinical setting.

CONCLUSIONS

Patient referrals for endoscopic services in an open-access referral system contain unacceptably high numbers of errors, which place patients at risk for adverse outcomes from endoscopic procedures.

Comparison of glucagon and scopolamine butylbromide as premedication for colonoscopy in unsedated patients

PURPOSE

Premedication with glucagon or hyoscyamine is reported to be effective in reducing colonic spasm. However, these drugs can be associated with unfavorable events. This prospective study was designed to compare the effects of premedication with glucagon with those of scopolamine butylbromide on cardiopulmonary parameters, intubation time, and patient discomfort in unsedated patients undergoing diagnostic colonoscopy.

METHODS

One hundred consecutive adult patients (65 males) undergoing colonoscopy without sedation were randomized to receive 1 mg of glucagon (n = 50) or 20 mg of scopolamine butylbromide (n = 50), intramuscularly. Physiologic changes, including systolic blood pressure, heart rate, and oxygen saturation, were monitored before colonoscope insertion and at three-minute intervals during colonoscopy. The percentages of completed procedure and time to cecal intubation were recorded. Patients were asked to rate pain by using a five-point pain score (0 = no pain; 4 = severe pain).

RESULTS

The percentages of completed procedure (96 vs. 98 percent), time to cecal intubation (16.3 vs. 14.5 minutes), and pain score (1.7 vs. 1.5) did not differ significantly between two groups. An increase in heart rate of more than ten beats per minute from baseline during colonoscopy occurred significantly more often in scopolamine group (44 percent of 50 patients) than in the glucagon group (12 percent of 50 patients; P = 0.0004). There were no significant differences between the two study groups with regard to changes in systolic blood pressure and decrease in oxygen saturation during colonoscopy.

CONCLUSIONS

Premedication with 1 mg of glucagon facilitates favorable examination with respect to physiologic changes compared with 20 mg of scopolamine. These features favor glucagon as the preferred premedication for patients undergoing colonoscopy.

Incidence and management of colonoscopic perforations: 8 years’ experience

AIM: To review the experience of a major medical teaching center with diagnostic and therapeutic colonoscopies and to assess the incidence and management of related colonic perforations.

METHODS: All colonoscopies performed between January 1994 and December 2001 were studied. Data on patients, colonoscopic reports and procedure-related complications were collected from the departmental computerized database. The medical records of the patients with post procedural colonic perforation were reviewed.

RESULTS: A total of 12 067 colonoscopies were performed during the 8 years of the study. Seven colonoscopic perforations (4 females, 3 males) were diagnosed (0.058%). Five occurred during diagnostic and two during therapeutic colonoscopy. Six were suspected during or immediately after colonoscopy. All except one had signs of diffuse tenderness and underwent immediate operation with primary repair done in 4 patients. No deaths were reported.

CONCLUSION: Perforation rate during colonoscopy is low. Nevertheless, it is a serious complication and its early recognition and treatment are essential to optimize outcome. In patients with diffuse peritonitis early operative intervention makes primary repair a safe option.

Stress ulcer bleeding

Although upper gastrointestinal (GI) bleeding from stress-related mucosal disease (SRMD) in critically ill patients is common, significant bleeding with hemodynamic instability is not. Risk factor assessment can assist in identifying patients with a greater likelihood of developing significant SRMD. Prophylaxis against stress ulcer bleeding with luminal agents (eg, antacids and sucralfate) or drugs that inhibit acid secretion (eg, histamine 2-receptor antagonists and proton-pump inhibitors) can reduce major bleeding but has little or no effect on mortality. Currently, the mainstays of prophylactic therapy for SRMD are intravenously administered H2RAs and PPIs. Wider usage of PPIs reflects their enhanced efficacy in suppressing acid secretion as well as lack of tolerance for H2RAs. Guidelines for the prophylactic use of H2RAs or PPIs in treatment of SRMD will require large, randomized studies that also examine cost effectiveness of individual strategies.

Mallory - weiss tear complicating intraoperative transesophageal echocardiography

A Mallory - Weiss tear occurred as a complication of intraoperative transesophageal echocardiography carried out in a 62-year-old man who underwent coronary artery bypass grafting. Left ventricular function was monitored in the transgastric short-axis view. Postoperative esophagogastroscopy revealed a Mallory - Weiss tear at the gastroesophageal junction and erosions in the cardia, presumably secondary to contact pressure by the echoprobe and ultrasonic thermal injury. When not actively imaging, the echoprobe should be left free in the esophagus with the acoustic power off.

Systematic evaluation of complications related to endoscopy in a training setting: A prospective 30-day outcomes study

BACKGROUND

The 30-day frequency of negative outcomes after outpatient endoscopy performed by gastroenterology fellows is unknown.

METHODS

Questionnaires were mailed to 1000 consecutive patients 30 days after endoscopy to evaluate procedure-related negative outcomes (serious and minor adverse events) and patient satisfaction. Serious adverse events were defined as follows: oversedation requiring administration of a reversal agent, and those that resulted in a physician visit, emergency department visit, admission to the hospital, or death. Minor adverse events were defined as all problems other than serious adverse events that patients related to their endoscopic procedure.

RESULTS

The 30-day frequency of negative outcomes in the 869 patients who responded was 14.3%, of which 0.6% were serious and 13.7% were minor adverse events. The frequency of negative outcomes was 17.1% for EGD, 15.0% for colonoscopy, 24.4% for combined EGD and colonoscopy, and 7.8% for flexible sigmoidoscopy. One hundred percent of the serious adverse events were known to us, but only 16.0% of minor adverse events (p < 0.001). Multiple logistic regression identified midazolam dose (OR for each 1 mg increase in dose 4.5; 95% CI [2.7, 7.3]; p < 0.001), treatment with warfarin (OR 3.0; 95% CI [1.4, 6.2]; p = 0.003), comorbid disease (OR 2.1; 95% CI [1.3, 3.4]; p = 0.001), endoscopy performed in July or August (OR 2.0; 95% CI [1.1,3.7]; p = 0.02), and age (OR for each 1 year increase in age 1.03; 95% CI [1.01, 1.05]; p = 0.01) as independent predictors of negative outcomes. There was a significant association between negative outcomes and decreased patient satisfaction, and patients who reported negative outcomes were less likely to agree to endoscopy in the future.

CONCLUSIONS

Serious adverse events were rare after endoscopy performed by gastroenterology fellows. Contacting patients 30 days after outpatient endoscopy significantly improved the detection of negative outcomes. Although the majority of negative outcomes were minor, these adverse events were associated with decreased patient satisfaction.

Safety and efficacy of glucagon as a premedication for upper gastrointestinal endoscopy--a comparative study with butyl scopolamine bromide

BACKGROUND

Glucagon inhibits digestive motility and is used for endoscopic premedication; however, its effect on cardiopulmonary function during endoscopy has not yet been fully investigated.

AIM

To clarify the efficacy and safety of glucagon compared with butyl scopolamine bromide as upper gastrointestinal endoscopy premedication.

METHODS

Two hundred and forty consecutive patients over 40 years of age, referred for upper gastrointestinal endoscopy, without any complications, were studied. These patients were randomly premedicated with butyl scopolamine bromide (SC group) or glucagon (G group). Time course changes in blood pressure, arterial oxygen saturation, heart rate and the number of retching episodes during endoscopy were examined. The efficacy of glucose tablets after upper gastrointestinal endoscopy to prevent hypoglycaemia caused by glucagon was evaluated. Cardiopulmonary parameters were also examined in 77 complicated patients with glucagon premedication (GC group).

RESULTS

A continuous increase in heart rate during upper gastrointestinal endoscopy was observed in the SC group, but not in the G and GC groups. Blood pressure, arterial oxygen saturation and number of retching episodes were not different between the groups. Hypoglycaemia-related symptoms were frequent in the G group without glucose tablets, but were prevented by the administration of glucose.

CONCLUSIONS

Glucagon has a weaker effect on cardiopulmonary function during upper gastrointestinal endoscopy than butyl scopolamine bromide. Glucose administration prevents hypoglycaemia-related symptoms caused by glucagon.

Clinical application of a new colonoscope with variable insertion tube rigidity: a pilot study

BACKGROUND

Colonic loop formation can prolong colonoscopy, increase patient discomfort, and preclude complete examination. A colonoscope with variable insertion tube rigidity may facilitate colonoscopy. Our aim was to determine whether the use of a colonoscope with variable insertion tube rigidity reduces insertion time and improves patient acceptance of colonoscopy.

METHODS

Fifty patients were randomly assigned to undergo colonoscopy with a conventional colonoscope or a variable rigidity colonoscope (VRC). Patient acceptance, dosage of medication, use of abdominal pressure, and patient repositioning were assessed. Statistical analysis was performed by the 2-sample Wilcoxon rank sum test and an extension of Fisher exact test.

RESULTS

The groups were comparable with respect to age, gender, and medications required during colonoscopy. The cecum was reached in all 25 patients who underwent colonoscopy with the VRC, including 1 patient in whom the cecum was not reached at a previous colonoscopy with a conventional instrument. In the conventional colonoscopy group, the cecum was not reached in 4 patients (2 poor preparation, 2 loop formation). There was no significant difference between the 2 groups with respect to insertion time. In the group that underwent colonoscopy with the variable rigidity instrument, less abdominal pressure was required (p = 0.05), and nursing assessment of patient discomfort was more favorable (p = 0.05). There were no complications and no significant differences in the intubation time to cecum or in repositioning, patient acceptance, or patient assessment of abdominal pain.

CONCLUSION

The use of a variable rigidity colonoscope reduced the frequency of abdominal pressure but did not affect intubation time to cecum, repositioning, patient acceptance, or patient assessment of abdominal pain.

Endoscopic perforation of the colon: lessons from a 10-year study

OBJECTIVES

To assess the incidence, clinical features, and management of endoscopic colon perforations in a large number of patients at a major medical teaching center.

METHODS

A retrospective review of medical records of all patients with colon perforations from endoscopy over a 10-yr period.

RESULTS

A total of 10,486 colonoscopies were performed over a 10-yr period. There were 20 (0.19%) perforations and two (0.019%) deaths related to colonoscopy and two perforations with no deaths in 49,501 sigmoidoscopies (0.004%). The majority of perforations (65%) occurred in the sigmoid colon. The mean age of the patients was 72 yr (range, 48-87 yr). Multivariate analysis using gender and age showed that female gender was an independent predictor of a higher risk of perforation (p < 0.05). Electrocautery injury (36%) and mechanical injury (32%) from the tip and shaft of the endoscope were the major causes for perforation. Most patients (91%) presented within 48 h of endoscopy. Nine patients (47%) required a surgical resection with primary anastomosis; seven (37%) required a simple closure. The average hospital length of stay was 7.7 +/- 2.8 days. Although trainee endoscopists were involved in only 20% of the colonoscopies performed, eight (40%) perforations occurred while the training fellow was involved in the case. However, this increased risk of perforation with a training fellow was not statistically significant (p = 0.625).

CONCLUSIONS

Colonoscopy can result in significant morbidity and carries a small risk of death. Sigmoidoscopy has lower risk. The following situations may represent increased risk to colonoscopy patients: unusual difficulty in traversing the sigmoid colon; difficult examinations in female patients, and difficult examinations performed by trainee physicians.

Retroperitoneal duodenal perforation during endoscopic sphincterotomy: sonographic findings

We present the sonographic findings in 5 cases of retroperitoneal duodenal perforation during endoscopic sphincterotomy. In each case, sonography showed hyperechoic areas associated with shadowing and ring-down artifacts between the liver and the right kidney correlating with the retroperitoneal air seen on plain x-ray films. This brightly echogenic area with shadowing surrounded and obscured the kidney. In 4 patients, resolution was documented on follow-up sonographic examinations in agreement with other radiologic findings; the other patient died.

Clinical scoring systems for determining the prognosis of gastrointestinal bleeding

The prognosis of GI bleeding depends upon many factors. Patients should be evaluated carefully for risk factors. To avoid complications from GI bleeding, triage should be performed promptly after patient presentation. The history and physical examination should emphasize analysis of risk factors for severe GI bleeding and mortality. Factors that increase the morbidity and mortality include: age greater than 60 years; underlying comorbidity such as pulmonary diseases, liver diseases, renal diseases, encephalopathy, or cancer; physiologic stress from major surgery, trauma, or sepsis; coexisting disease in three organ systems; low hematocrit; melena or hematochezia; and prolonged prothrombin time. Hospitalized patients who require more than five units of packed erythrocytes transfusion or who develop hypotension or hypovolemic shock are more likely to need surgery. Patients with a high APACHE II score, the presence of esophageal varices, active bleeding, or other endoscopic stigmata of recent hemorrhage are more likely to rebleed and undergo surgery. The proliferation of multivariable prognostic scales, as described herein, provides ample evidence that the goal of developing a single comprehensive multivariable scale to accurately assess severity of disease and to determine prognosis of GI bleeding is still not achieved. Yet significant progress has occurred in this field, leading to the hope of developing a universally applicable multivariable scale.

Delayed mid-ileal perforation secondary to acute-on-chronic ischaemia after a diagnostic colonoscopy

Perforation occurring at a remote site of the bowel after diagnostic colonoscopy is rare. A 61-year-old man presenting with bloody diarrhoea underwent colonoscopy. A dynamic ileus developed in less than 1 day, and mid-ileal perforation occurred 7 days after the procedure. It is suggested that high air pressure during colonoscopy further compromised the reduced blood flow in the mid-ileum, which had underlying chronic ischaemia, leading to perforation. Our patient constitutes the first reported case of small-bowel perforation after colonoscopy due to pre-existent ileal ischaemia.

Recovery time and safe discharge of endoscopy patients after conscious sedation

The aim of this study was to identify the best method for determining when to safely discharge the endoscopy patient; specifically, it was designed to determine whether the patient's risk factors, intraoperative occurrences, and/or medications used during endoscopy should be used to determine the minimum length of stay postconscious sedation or whether a general policy can be used, as is currently practiced at many institutions. Preoperative, intraoperative, and postoperative data were collected on a convenience sample of 405 adult ambulatory outpatients undergoing upper endoscopy and/or colonoscopy. Subjects were also interviewed by phone within 48 hours of discharge to assess postdischarge complications and their duration. Age predicted length of time in recovery, but only 2% of the variation in recovery time was predicted by the study variables. Intraprocedure occurrences predicted postprocedure occurrence. The implications of these and other findings are discussed in relation to nursing practice and future research.

Management of foreign bodies of the upper gastrointestinal tract: update

Management of 242 foreign bodies of the upper gastrointestinal tract are reported. Thirty-nine were in the pharynx, 181 in the esophagus, 19 in the stomach, and 3 in the small bowel. The flexible panendoscope was used 211 times (87.2%) to manage these foreign bodies, while the rigid esophagoscope was used 12 times (5.0%). Two hundred thirty-nine foreign bodies (98.8%) were successfully managed endoscopically. The surgery rate was 0.4%. There was no morbidity or mortality. Twenty-five percent of the cases were done under general endotracheal anesthesia. Coins in the esophagus are removed promptly if in the cervical or mid esophagus, and within 12 hours if in the distal esophagus. Once in the stomach, they will usually pass without difficulty. Meat impaction resulting in an obstructed esophagus is an urgent problem and the bolus should be removed within hours. Sharp and pointed foreign bodies can be very difficult to manage. Dry runs with a reproduction of the foreign body are essential to successful removal. Button batteries lodged in the esophagus represent an emergency and should be removed without delay. Once in the stomach, they will usually pass through the gastrointestinal tract without difficulty. The forward-viewing flexible panendoscope has become the instrument of choice in managing foreign bodies in most tertiary medical centers as well as in the community hospitals.

Risk of bleeding after endoscopic biopsy or polypectomy in patients taking aspirin or other NSAIDS

The present study was performed to determine if the risk of bleeding after endoscopic biopsy or polypectomy was increased in patients taking aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). Of 694 patients who underwent either upper gastrointestinal endoscopy with biopsy or colonoscopy with biopsy or polypectomy, 320 (46%) had recently consumed NSAIDs. Postprocedure bleeding was assessed by both written questionnaire and telephone follow-up. A total of 32 patients (4.6%) reported bleeding. Minor, self-limited, clinically insignificant bleeding occurred in 20/320 (6.3%) patients taking NSAIDs and 8/374 (2.1%) control patients (p = .009). Major bleeding requiring hospitalization or treatment occurred in only 4 patients (0.58%) (2 from the control group and two from the drug group), each of whom had undergone colonic polypectomy. The risk of bleeding increased with polyp size, but this did not seem to be affected by NSAID use. We conclude that the risk of significant gastrointestinal bleeding after endoscopic biopsy or poly removal is small (< 1%). Although use of NSAIDs did increase the incidence of minor self-limited bleeding, an increase in the rate of major bleeding was not observed.

A prospective randomized trial comparing manual and automated endoscope disinfection methods

OBJECTIVE

To compare the efficacy of endoscope disinfection using automated and manual systems.

DESIGN

Prospective randomized trial.

SETTING

A 1,000-bed tertiary care referral center.

METHODS

All endoscopes underwent a three-stage decontamination process including brushing and cleaning with water and detergent, manual or automated disinfection with 2% glutaraldehyde, and 70% alcohol rinse with forced air drying. Cultures were obtained from endoscopes from both groups before and after alcohol rinse and then after overnight storage.

RESULTS

Cultures from 8/30 (27%) automated and 11/30 (37%) manually disinfected (P = 0.58) endoscopes grew gram-negative bacteria and/or nontuberculous mycobacteria before the alcohol rinse. After alcohol rinse, 3 (10%) of 30 automated and 8 (27%) of 30 manually disinfected endoscopes remained contaminated (P = 0.28). Manually disinfected endoscopes were contaminated more frequently with coliform bacteria, whereas endoscopes undergoing automated disinfection were more frequently contaminated with nontuberculous mycobacteria, but the differences were not statistically significant. After alcohol rinse and forced air drying, there was no difference in contamination rates between freshly disinfected endoscopes and those stored overnight (7/30 (23%) versus 4/30 (13%), P = 0.50). Colonoscopes and duodenoscopes were contaminated more often than gastroscopes (P = 0.00001).

CONCLUSION

The persistent endoscope contamination after manual and automated disinfection indicates the importance of developing more reliable and effective disinfection methods.

Low risk of gastroesophageal injury associated with transesophageal echocardiography during cardiac surgery

Transesophageal echocardiography (TEE) has increasingly been used in cardiology and cardiac surgery with few reported complications. This study was undertaken to determine whether TEE is associated with an increased incidence of gastroesophageal (GE) bleeding or postoperative GE symptoms of anorexia, dysphagia, or sore throat. Forty-one patients who underwent TEE during cardiac surgery and 40 control patients who underwent cardiac surgery without TEE were prospectively followed. In addition, a retrospective chart review of 200 patients who underwent TEE during cardiac surgery was also performed. The following information was derived from the patient interviews and chart reviews: (1) The development of both frank and occult upper gastrointestinal tract (UGI) bleeding; (2) the patient's preoperative anticoagulation status; and (3) the patient's subjective complaints of anorexia, dysphagia, or sore throat. The incidence of postoperative occult or frank UGI bleeding was not increased in the groups who underwent TEE. Additionally, the incidence of postoperative GE symptoms was comparable in the three groups. These findings are discussed in the context of reported complications associated with UGI endoscopy. Based on this analysis, recommendations for the safe performance of TEE have been provided.

Screening strategies for colorectal cancer

The efficacy of screening for colorectal cancer has not been established. Policy-making organizations differ in recommendations for asymptomatic and high-risk groups because of the inadequacy of current evidence. A critical appraisal of the current evidence for screening for colorectal cancer and a discussion of the aims and pitfalls of screening programs are presented.

Colonoscopic impaction in left colon strictures resulting in right colon pneumatic perforation

Colonic perforation during flexible colonoscopy is a rare but recognized complication. We reviewed 4,593 colonoscopies performed from 1984 to 1989. The perforation rate for diagnostic colonoscopy was 0.17% (6/3,538) and for therapeutic colonoscopy it was 2% (21/1,055). Four perforations of the right colon occurred at a site proximal to the level of the impacted colonoscope. The lesions being evaluated were obstructive in nature: two diverticular strictures (sigmoid colon), one ischemic stricture (descending colon), and one annular carcinoma (descending colon). The four perforations occurred in the right colon and manifested as distension with pneumoperitoneum or retroperitoneal emphysema. Operative management included total abdominal colectomy in two patients (ileoproctostomy in one and ileostomy in one) and right colectomy in two. Outcome was favorable in all cases.

Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications

Because transesophageal echocardiography is invasive, it has the potential for serious complications. Limitations occur because of the restricted transducer mobility within transducers for special situations. Pitfalls (potential erroneous diagnoses resulting from misinterpretation of normal and abnormal anatomy) are prevalent with this new technology. This report critically reviews transesophageal echocardiography and discusses and illustrates commonly encountered limitations, pitfalls, and complications.

Pneumomediastinum as a complication of upper gastrointestinal endoscopy

Secondary or complex pneumomediastinum following esophagoscopy is due to an esophageal perforation. Primary or simple pneumomediastinum may be caused by maneuvers such as coughing, gagging, swallowing, choking, and valsalva. These maneuvers are common during upper gastrointestinal endoscopy. Esophageal perforation is a potentially life threatening event, while simple pneumomediastinum is usually a benign self-limited disorder. Although the presentation may be similar, different morbidities compel prompt evaluation for distinction between these two entities and appropriate management. We present a case of pneumomediastinum that developed immediately following upper gastrointestinal endoscopy. Implications of diagnosis, management, and prognosis are discussed.

Esophageal and gastric endoscopy in critically ill patients. How can it help you?

Bleeding from the upper gastrointestinal tract in a critically ill patient is a tough diagnostic situation. Endoscopy can help physicians determine the cause of bleeding and can also provide several therapeutic options. The authors discuss these applications of the current technology.

Percutaneous endoscopic vs surgical gastrostomy

The percutaneous endoscopic gastrostomy (PEG) has replaced the surgical gastrostomy (GT) on our service. We reviewed our data in an effort to determine relative efficacy and cost effectiveness of the two techniques. Thirty-five patients with PEGs were matched for age and diagnosis with 35 patients with GTs done by the same surgical service. PEGs were done in the endoscopy suite; GTs were done in the operating room: both under local anesthesia. Patients in PEG and GT groups were comparable in sex, diagnosis, and age. The PEG took less time to insert (15.3 vs 25.4 min, p less than 0.001). Major postoperative morbidity was similar with 10 systemic complications for each group and 11 deaths for the PEG vs 12 deaths for the GT group (at 90 days). Minor morbidity was higher for the PEG group with nine complications vs 1. Estimated cost for PEG was half the cost of GT. Hospital stay for the two groups was similar (36 vs 45 days, p greater than 0.1), but postop stay for the PEG group tended to be shorter (17 vs 24 days, p less than 0.08). The PEG is faster and cheaper to insert than the GT, however major morbidity and mortality are the same.

Characteristic appearances of colonic lipomas on barium enema: a guide to conservative management

The double contrast barium enema appearances of seven colonic lipomas are reviewed. These lesions have submucosal features: intact mucosa, sharp margination and obtuse angles between the lesion and the adjacent colonic wall, as well as features characteristic of lipomas: pliability and shape change, broad pedicles and spherical appearances en face. They can be differentiated from the more significant colonic adenomas and then CT scanned to establish a histological diagnosis. The need for colonoscopic or surgical excision of these predominantly asymptomatic lesions occurring in elderly patients can be considerably reduced.

Management of colonic perforation after colonoscopy. Report of three cases

In a review of 5424 colonoscopies performed in the last ten years at Bronx-Lebanon Hospital Center, 14 perforations related to the procedure were found. Seven perforations occurred during therapeutic colonoscopies (polypectomies) and seven during diagnostic colonoscopies. Eight patients were treated surgically and six nonsurgically. The decision about whether or not to perform surgery for a colonoscopically induced perforation depends on the clinical condition of the patient. Nonsurgical management is indicated if the patient's general condition remains stable, if the perforation has been diagnosed late, if the pneumoperitoneum that led to the diagnosis does not increase in size, if there are no signs of peritonitis, if the patient does not have a distal obstruction, and if the patient's condition improves in response to conservative treatment.

Complications and hazards of gastrointestinal endoscopy

The diagnostic and therapeutic contribution of fiberoptic endoscopy to the advancement of the knowledge of gastrointestinal disease and to its proper management is already established. Technical refinements in the new instruments and extensive acceptance of the advantages of the method makes fiberendoscopy a procedure widely used throughout the world. Therefore, the appreciation of its potential risk of complications and hazards is justified. This review summarizes the complications and hazards of fiberoptic gastrointestinal endoscopy gleaned from reports of endoscopic surveys and individual experiences. Causes and means whereby complications related to upper intestinal and colonic endoscopy can be prevented or treated are discussed.

Screening for colorectal cancer: a critical review

This article discusses the place of symptom detection, endoscopy, and fecal occult blood testing in population screening for colorectal cancer. There is now considerable evidence that screening the population over the age of 50 years for occult blood in the feces will result in an increased yield of tumors localized to the bowel at the time of surgical treatment. These tumors also have other favorable prognostic features and it is likely that the prognosis of this group will be better than the prognosis of patients presenting with symptoms in the usual way. Because of the biases that result from the selection and detection of tumors in screening studies, the mortality results of the control trials now underway must be awaited until it is known whether population screening is of real value. In chemical fecal occult blood screening tests, a compromise has to be made between sensitivity and specificity. The fecal occult blood test most widely used and the one that has been subjected to the most evaluation in screening studies is the guaiac-based slide test, Hemoccult. The predictive value of a positive test for invasive cancer is 11-17%, and for adenomas, 36-41%. This specificity is achieved at a loss of sensitivity, the interval cancer rate reported in screening studies being over 20%. Newly developed immunological techniques appear to be more sensitive and specific, but require further evaluation in population screening studies.