Simultaneous dual scope endotherapy of esophago-airway fistulas and obstructions

Management of esophago-airway fistulas (EAF) and obstructions often involves therapy with esophageal and/or airway stents. We present a unique approach for the management of EAF and obstructions with simultaneous upper endoscopy and bronchoscopy (two scopes inserted simultaneously through the mouth). The aim is to assess the efficacy and safety of a simultaneous dual scope approach for management of EAF and obstructions. The endoscopy database at the University of Florida was reviewed from October 2007 to April 2012 to identify adult patients who had undergone simultaneous upper endoscopy and bronchoscopy for EAF and obstructions. Medical records were reviewed for demographics, indication, pathology, imaging, simultaneous endoscopic and bronchoscopic findings/maneuvers, outcomes, and adverse events. Outcomes assessed included: (i) technical success, (ii) fistula occlusion, (iii) dysphagia score, and (iv) adverse events. Thirteen patients with EAF and/or obstruction underwent simultaneous dual scope endoscopy. Dual scope procedures were technically successful in 12/13 (92%) patients. Dysphagia score improved from three to one in both patients with dysphagia without EAF. Fistula occlusion was observed in 7/10 patients (70%) with EAF. With this technique, stents were placed accurately without airway compression, migrated esophageal stents extracted from the tracheal lumen without trauma, and tracheal stents not displaced during esophageal manipulations. EAF not otherwise apparent were identified in two patients. Adverse events occurred in 2/13 (15%) patients, and 5/13 (38%) patients died from advanced cancer during follow up (mean 4.1 months, range 1-8 months). Simultaneous dual scope (two scopes inserted through the mouth at the same time) therapy of EAF and obstructions is feasible, effective, and safe, and may develop to be the preferred approach for the management of complex esophago-airway diseases.

[Multidisciplinar international classification of the severity of acute pancreatitis: Italian version 2013]

AIM

The aim of this paper was to present the 2013 Italian edition of a new international classification of acute pancreatitis severity. The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric description of occurrences that are merely associated with severity.

METHODS

A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists, and radiologists who are currently active in clinical research on acute pancreatitis. A global web-based survey was conducted and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULTS

The new international classification is based on the actual local and systemic determinants of severity, rather than description of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity-mild, moderate, severe, and critical.

CONCLUSION

This classification provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research.

[International multidisciplinary classification of acute pancreatitis severity: the 2013 Spanish edition]

OBJECTIVE

To develop a new classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of the published evidence, and worldwide consultation.

BACKGROUNDS

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of specialist in pancreatic diseases, but are suboptimal because these definitions are based on the empiric description of events not associated with severity.

METHODS

A personal invitation to contribute to the development of a new classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensivists and radiologists currently active in the field of clinical acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global web-based survey was conducted, and a dedicated international symposium was organized to bring contributors from different disciplines together and discuss the concept and definitions.

RESULTS

The new classification of severity is based on the actual local and systemic determinants of severity, rather than on the description of events that are non-causally associated with severity. The local determinant relates to whether there is (peri) pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another, whereby the presence of both infected (peri) pancreatic necrosis and persistent organ failure has a greater impact upon severity than either determinant alone. The derivation of a classification based on the above principles results in four categories of severity: mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process among specialists in pancreatic diseases from 49 countries spanning North America, South America, Europe, Asia, Oceania and Africa. It provides a set of concise up to date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

[Determinant-based classification of acute pancreatitis severity. International multidisciplinary classification of acute pancreatitis severity: the 2013 German edition]

OBJECTIVE

The aim of this study was to develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation.

BACKGROUND

The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric descriptions of occurrences that are merely associated with severity.

METHODS

A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensive medicine specialists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organised to bring contributors from different disciplines together and discuss the concept and definitions.

RESULT

The new international classification is based on the actual local and systemic determinants of severity, rather than descriptions of events that are correlated with severity. The local determinant relates to whether there is (peri)pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri)pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity - mild, moderate, severe, and critical.

CONCLUSIONS

This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

Use and perceived effectiveness of non-analgesic medical therapies for chronic pancreatitis in the United States

BACKGROUND

Effectiveness of medical therapies in chronic pancreatitis has been described in small studies of selected patients.

AIM

To describe frequency and perceived effectiveness of non-analgesic medical therapies in chronic pancreatitis patients evaluated at US referral centres.

METHODS

Using data on 516 chronic pancreatitis patients enrolled prospectively in the NAPS2 Study, we evaluated how often medical therapies [pancreatic enzyme replacement therapy (PERT), vitamins/antioxidants (AO), octreotide, coeliac plexus block (CPB)] were utilized and considered useful by physicians.

RESULTS

Oral PERT was commonly used (70%), more frequently in the presence of exocrine insufficiency (EI) (88% vs. 61%, P < 0.001) and pain (74% vs. 59%, P < 0.002). On multivariable analyses, predictors of PERT usage were EI (OR 5.14, 95% CI 2.87-9.18), constant (OR 3.42, 95% CI 1.93-6.04) or intermittent pain (OR 1.98, 95% CI 1.14-3.45). Efficacy of PERT was predicted only by EI (OR 2.16, 95% CI 1.36-3.42). AO were tried less often (14%) and were more effective in idiopathic and obstructive vs. alcoholic chronic pancreatitis (25% vs. 4%, P = 0.03). Other therapies were infrequently used (CPB - 5%, octreotide - 7%) with efficacy generally <50%.

CONCLUSIONS

Pancreatic enzyme replacement therapy is commonly utilized, but is considered useful in only subsets of chronic pancreatitis patients. Other medical therapies are used infrequently and have limited efficacy.

Prospective evaluation of gastroenterologist-guided, nurse-administered standard sedation for spiral deep small bowel enteroscopy

BACKGROUND

Sedation of patients for deep small bowel enteroscopy presents unique challenges and is traditionally provided by anesthesiologists. No study has directly evaluated gastroenterologist-guided, nurse-administered sedation for deep enteroscopy. Further, no comparison exists between gastroenterologist-guided versus anesthesiologist-guided sedation during deep enteroscopy.

AIMS

To evaluate safety and efficacy of performing deep (spiral) enteroscopy using gastroenterologist-guided sedation and compare outcomes between patients receiving gastroenterologist-guided and anesthesiologist-guided sedation.

METHODS

This prospective case series contains 91 consecutive patients who underwent deep enteroscopy with spiral Endo-Ease Discovery SB overtube. Of the patients, 64 received gastroenterologist-guided and 27 received anesthesiologist-guided sedation.

RESULTS

In the 64 patients receiving gastroenterologist-guided sedation, successful completion occurred in 59 of 64 enteroscopies (92.2%). Mean insertion depth was 231.0+/-85.8 cm beyond the ligament of Treitz. Total procedure time was 39.9+/-15.7 min (diagnostic time 34.7+/-12.3 min; therapy time 5.2+/-8.9 min). Positive findings were noted in 32 cases (50.0%), with therapy performed in 27 cases (42.2%). Six minor complications occurred. Compared to the anesthesiologist-guided sedation group, there was no difference in patient characteristics except mean American Society of Anesthesiologists score (2.5+/-0.5 in gastroenterologist-guided group versus 2.7+/-0.6 in anesthesiologist-guided group; p=0.046) and presence of adhesions (ten in gastroenterologist-guided group and zero in anesthesiologist-guided group; p=0.030). Outcomes for both groups were not significantly different except for shorter times in the gastroenterologist-guided group (39.9+/-15.7 min versus 46.0+/-12.1 min; p=0.047) and more frequent findings in the anesthesiologist-guided group (50.0% vs. 74.1%; p=0.034).

CONCLUSIONS

Deep enteroscopy using the spiral overtube can be successfully and safely accomplished with gastroenterologist-guided, nurse-administered standard sedation.

Review article: pain and chronic pancreatitis

BACKGROUND

Pain in chronic pancreatitis chronic pancreatitis is a frustrating and challenging symptom for both the patient and clinician. It is the most frequent and most significant symptom. Many patients fail the currently available conservative options and require opiates or endoscopic/surgical therapy. Aim To highlight the pathophysiology and management of chronic pancreatitis pain, with an emphasis on recent developments and future directions.

METHODS

Expert review, utilizing in addition a comprehensive search of PubMed utilizing the search terms chronic pancreatitis and pain, treatment or management and a manual search of recent conference abstracts for articles describing pain and chronic pancreatitis.

RESULTS

Pancreatic pain is heterogenous in its manifestations and pathophysiology. First-line medical options include abstinence from alcohol and tobacco, pancreatic enzymes, adjunctive agents, antioxidants, and non-opiate or low potency opiate analgesics. Failure of these options is not unusual. More potent opiates, neurolysis and endoscopic and surgical options can be considered in selected patients, but this requires appropriate expertise. New and better options are needed. Future options could include new types of pancreatic enzymes, novel antinociceptive agents nerve growth factors, mast cell-directed therapy, treatments to limit fibrinogenesis and therapies directed at the central component of pain.

CONCLUSIONS

Chronic pancreatitis pain remains difficult to treat. An approach utilizing conservative medical therapies is appropriate, with more invasive therapies reserved for failure of this conservative approach. Treatment options will continue to improve with new and novel therapies on the horizon.

Three-year oral pantoprazole administration is effective for patients with Zollinger-Ellison syndrome and other hypersecretory conditions

BACKGROUND

Zollinger-Ellison syndrome and idiopathic hypersecretion are gastrointestinal hypersecretory conditions requiring long-term maintenance.

AIMS

The safety and efficacy data for short-term (6-month) treatment of Zollinger-Ellison syndrome and idiopathic hypersecretion with oral pantoprazole were previously published. This study extends the initial observations to 3 years.

METHODS

The primary efficacy end point for this report was the control of gastric acid secretion in the last hour before the next dose of oral pantoprazole (acid output of <10 mmol/h; <5 mmol/h in subjects with prior acid-reducing surgery). Dose titration was permitted to a maximum of 240 mg per 24 h.

RESULTS

Twenty-four subjects completed the study. The acid output of 28 of 34 subjects was controlled at initial enrolment. The mean acid output rates were <10 mmol/h throughout the 36 months of treatment for 90-100% of the patients. The majority of the patients were controlled with b.d. doses of 40 or 80 mg pantoprazole at 36 months (acid output was controlled in 24 of 24 subjects). Pantoprazole was generally well tolerated with minimal adverse events reported.

CONCLUSIONS

Maintenance oral pantoprazole therapy up to 3 years at dosages of 40-120 mg b.d. was effective and well tolerated in patients with Zollinger-Ellison syndrome and other hypersecretory conditions.

Review article: Pancreatic function testing

Pancreatic function tests are most commonly used to diagnose chronic pancreatitis. These tests include tests which document exocrine or endocrine gland insufficiency and tests which instead measure gradations of decreased secretory capacity. The tests in the former category generally become abnormal when advanced, longstanding chronic pancreatitis is present. Tests in the latter category, however, have the potential to detect chronic pancreatitis at an earlier stage than other available diagnostic tests, including commonly used imaging tests such as computed tomography and endoscopic retrograde cholangiopancreatography. This potential advantage of diagnostic sensitivity is, however, counterweighed by the fact that these tests which measure stimulated secretory capacity are only available at a very few referral centres. This article will review the variety of pancreatic function tests and describe their rationale, accuracy, cost, and clinical usefulness.

Pancreatic and biliary disorders in the elderly

Structural and functional changes in the biliary tract and pancreas associated with advanced age are well documented in the literature and must be taken into account in evaluating patients with possible biliary and pancreatic disorders. The relationship between normal, age-related physiologic changes and various pancreatico-biliary diseases is not well defined. Elderly patients may present with severe biliary and pancreatic disease that may pose difficult management problems because of coexisting medical illnesses. Despite these challenges, all but the most frail elderly patients can benefit from appropriate medical, endoscopic, and surgical therapy.

Effect of bile and pancreatic juice on adenoviral-mediated gene delivery: implications on the feasibility of gene delivery through ERCP

Current research in gene delivery to the liver is focused on the intravenous, intraarterial, intraportal, or intratumoral route. Another possible route for gene delivery is via the common bile duct through endoscopic retrograde cholangiopancreatography (ERCP). Whether bile and pancreatic juice have any effect on gene delivery is not established. To evaluate the effect of bile and pancreatic juice on adenoviral-mediated gene delivery, liver and pancreatic cell lines were infected with a recombinant adenovirus expressing an E. coli beta-galactosidase gene under the control of a cytomegalovirus promoter (rAdCMVpLacZ) in the absence or presence of various concentrations of bile and pancreatic juice. The proportion of cells infected was evaluated through X-gal staining. The toxicity of bile and pancreatic juice was also evaluated through cell morphology and detachment. Bile appeared to induce significant cytotoxicity in HepG2 and Huh7 cells (50% viability with 15 min of incubation). Neither bile nor pancreatic juice affected transgene expression. In the absence of bile/pancreatic juice, HepG2 (15-25%) and PANC-1 cells (10-18%) were less susceptible to rAdCMVpLacZ compared to Huh7 cells (75-84%, vs HepG2, P < 0.001) and BxPc-3 (82-95%, vs PANC-1, P < 0.001) at a multiplicity of infection (MOI) of 5. Bile reduced the transduction efficiency, but 5-10% HepG2 and 5-42% of Huh7 cells were still transduced in the presence of 80% bile for up to 10 min. Adenoviral-mediated gene delivery was reduced in the presence of pancreatic juice with a low multiplicity of infection (MOI of 5), but this effect was negated with an MOI of 50. These data provide encouragement to develop adenoviral-mediated gene delivery through ERCP.

Mirizzi syndrome: A rare cause of obstructive jaundice

Mirizzi syndrome is a rare cause of bile duct obstruction secondary to extrinsic compression of the hepatic duct by stones impacted in the cystic duct or infundibulum of the gallbladder. The suspicion of Mirizzi syndrome primarily relies on radiographic means such as ultrasound, computed tomography and cholangiography. The recognition of this rare syndrome is crucial in developing the proper treatment approach. We present 3 cases of Mirizzi syndrome and a review of the literature pertaining to the diagnosis and treatment of this rare cause of obstructive jaundice.

Monolobar Caroli's Disease and cholangiocarcinoma

Caroli's Disease (CD) is a rare congenital disorder characterized by cystic dilatation of the intrahepatic bile ducts. This report describes a patient with cholangiocarcinoma arising in the setting of monolobar CD. In spite of detailed investigations including biliary enteric bypass and endoscopic retrograde cholangiography, the diagnosis of mucinous cholangiocarcinoma (CCA) was not made for almost one year. The presentation, diagnosis and treatment of monolobar CD and the association between monolobar CD and biliary tract cancer are discussed. Hepatic resection is the treatment of choice for monolobar CD.

Pancreatic duct stenting in benign pancreatic disease

The ability to place endoscopic stents into the pancreatic duct has led to a dramatic increase in stent therapy for benign pancreatic diseases, particularly chronic pancreatitis and pancreas divisum. The overall effectiveness of this therapy remains unknown. This article critically reviews the available literature with a focus on patient selection, efficacy, and risk. The risk of pancreatic duct stenting is only now beginning to be appreciated, and clinicians must understand not only the potential effectiveness of pancreatic duct stenting but also the magnitude of the potential risk when considering this therapy.

Differential diagnosis of pancreatic tumors

Endosonography is the most sensitive method to detect even small pancreatic tumors. A number of endosonographic criteria have been evaluated, but there are not specific features that allow malignant tumors to be differentiated from benign tumors. The role and timing of endoscopic ultrasound as part of a more diagnostic evaluation in patients with pancreatic tumors is not yet defined.

Acute pancreatitis. Medical management

The medical management of acute pancreatitis is primarily supportive and involves making the patient nulla per os, providing adequate intravenous hydration, and controlling pain with analgesics. Systems to identify patients with severe pancreatitis at risk for morbidity and mortality are available but require supplementation with frequent, experienced clinical observation. A number of modalities to inhibit pancreatic secretion or pancreatic proteases have not been successful in clinical trials, although larger studies in patients with more severe pancreatitis are required to ultimately assess their effectiveness. The empiric use of imipenem and long-term peritoneal lavage in patients with severe or necrotizing pancreatitis appear promising but further studies are needed. The removal of impacted gallstones in patients with severe pancreatitis or cholangitis is useful, provided an expert endoscopist is available. Improvements in our ability to document pancreatic infection early by CT-directed aspiration have markedly improved our ability to manage pancreatic infection.

What does an abnormal pancreatogram mean?

The foregoing discussion emphasized the fact that pancreatography can document changes that are relatively specific for chronic pancreatitis but that similar changes can be seen in other clinical conditions and even as normal variants. In addition, the exact clinical implication of minor or equivocal changes is unclear and care should be taken not to overinterpret ERP findings. It also must be realized that ERP may miss a substantial number of patients with earlier or less advanced chronic pancreatitis. ERP also may document pancreas divisum, but is not helpful in explaining the patient's clinical condition in the absence of dorsal duct abnormalities. Finally, tests of pancreatic function--in particular, hormonal stimulation tests--are complementary to tests of pancreatic morphology and allow the diagnosis of less advanced or earlier chronic pancreatitis, as well as patients with divisum and normal dorsal ducts who nonetheless have obstruction to flow at the minor papilla. The evaluation of a patient with presumed chronic pancreatitis therefore should begin with simple, noninvasive tests that are able to detect advanced forms of chronic pancreatitis. These include plain abdominal radiograph and serum trypsin. If either of these is markedly abnormal, no further diagnostic testing is generally required. In patients in whom diagnostic uncertainty still exists, reasonable second-echelon tests include abdominal CT, bentiromide testing, or secretin stimulation testing. Of these, hormonal stimulation testing offers the most sensitivity but is not universally available. More invasive evaluations--in particular, ERP--should be reserved for patients in whom the diagnosis is still unclear or in whom therapeutic rather than diagnostic information is required (e.g., a patient classified a medical failure being considered for Peustow procedure).

Diagnosis of pancreatic cancer and prediction of unresectability using the tumor-associated antigen CA19-9

Marked elevations of the tumor-associated antigen CA19-9 are relatively specific for pancreatic carcinoma and are associated with more advanced malignancies. We retrospectively reviewed 53 patients with CA19-9 values > 90 U/ml in whom the test had been done because of clinical suspicion of pancreatic malignancy. Pancreatic cancer was found in 45 patients (85%). If a cutoff value of CA19-9 > 200 U/ml is used, 36 of 37 (97%) patients had pancreatic cancer. Thirty patients with pancreatic cancer and no radiographic criteria of unresectability underwent attempted resection; five of these patients were judged to be potentially resectable and four of them underwent attempted resection. In only one patient with a CA19-9 value > 300 U/ml was resection possible; this patient had advanced carcinoma. Our results suggest that, in patients in whom the clinician suspects pancreatic carcinoma, CA19-9 > 90 U/ml is highly suggestive of pancreatic malignancy, while CA19-9 > 200 U/ml is virtually diagnostic of pancreatic malignancy. In similar patients with CA19-9 > 300 U/ml, resection is rarely possible and tumors are advanced.

AIDS and the gastrointestinal tract

Gastrointestinal disease in AIDS most often affects three major areas: the bowel, the esophagus, and the liver. Investigation should be tailored to identify treatable causes of disease, bearing in mind that multiple infections, superinfection, and untreatable diseases are common. Clinical decisions must be made regarding both the level of investigation necessary and the best testing procedures to use. Treatment is often only symptomatic, but in some cases a specific pathogen can be targeted.

Cytomegalovirus peritonitis in a patient with the acquired immunodeficiency syndrome

Peritonitis has been reported infrequently in patients with the acquired immunodeficiency syndrome (AIDS). Intestinal or colonic perforation resulting from cytomegalovirus (CMV) enteritis is the most common cause of peritonitis in these patients. We report a patient with CMV peritonitis occurring in the absence of perforation (primary peritonitis) to alert physicians to this potentially treatable disorder.

Effect of octreotide on refractory AIDS-associated diarrhea. A prospective, multicenter clinical trial

OBJECTIVE

To determine the efficacy and safety of octreotide for treatment of refractory, profuse diarrhea in patients with the acquired immunodeficiency syndrome (AIDS).

DESIGN

A prospective, open-label study.

SETTING

Inpatient metabolic units of four university medical centers.

PATIENTS

Fifty-one patients infected with human immunodeficiency virus (HIV) who had uncontrolled diarrhea (greater than or equal to 500-mL liquid stool per day) despite treatment with maximally tolerable doses of antidiarrheal medications.

INTERVENTION

After initial baseline studies, patients received octreotide, 50 micrograms every 8 hours for 48 hours. If stool volume was not reduced to less than 250 mL/d, the dose of octreotide was increased stepwise to 100, 250, and 500 micrograms.

MAIN RESULTS

Fifty men and one woman (mean age, 36.3 +/- 1.1 years) entered and completed the 28-day protocol (14 days of inpatient therapy and 14 days of outpatient therapy). Stool frequency and volume decreased significantly (6.5 +/- 0.5 stools per day on day 0 compared with 3.8 +/- 0.3 stools per day on day 21 [P less than 0.001] and 1604 +/- 180 mL/d on day 0 compared with 1084 +/- 162 mL/d on day 14 [P less than 0.001], respectively). Twenty-one patients (41.2%) were considered to be partial or complete responders (reduction in daily stool volume by greater than or equal to 50% of initial collections or reduction to less than or equal to 250 mL/d). Of the 21 responders, 14 (67%) had no identifiable pathogens at initial screening compared with 9 of 30 (30%) nonresponders (P less than 0.01).

CONCLUSION

Patients with AIDS-associated refractory watery diarrhea, especially those without identifiable pathogens, may respond favorably to subcutaneously administered octreotide. This drug deserves further study in a randomized, placebo-controlled trial.

Characterization of human immunodeficiency virus type 1 strains recovered from the bowel of infected individuals

HIV-1 isolates were recovered from biopsy tissues from the small bowel, colon, and rectum of 10 infected individuals with severe diarrhea. In general, the bowel strains grew well in primary macrophage and lymphocyte cultures, not in T or B cell lines. They induced cytopathic effects such as syncytia formation and cell killing in peripheral blood mononuclear cells and were usually sensitive to serum neutralization. Several of these isolates were able to infect bowel epithelial cell lines, but this characteristic was also observed with blood-derived strains. Differences could be identified in 3 of 6 cases of paired bowel and blood isolates from the same individual. When compared to blood-derived isolates, the bowel strains exhibited a relative inability to grow in established cell lines, a reduced ability to induce cytopathology in infected cells, and a greater sensitivity to serum neutralization. Thus, although distinct characteristics of bowel-derived HIV-1 strains were not found, certain biological and serological properties might differentiate these viruses from those isolated from other tissues.

High-protein ascites in patients with the acquired immunodeficiency syndrome

Diseases of the liver or peritoneum resulting in ascites have been infrequently reported in patients with the acquired immunodeficiency syndrome. Since 1985, eight noncirrhotic patients with the acquired immunodeficiency syndrome presenting with new onset high-protein ascites have been evaluated. All but one patient had nondiagnostic paracentesis studies. Laparoscopy with biopsy of identified abnormalities or percutaneous omental biopsy were diagnostic in four patients. Non-Hodgkin's lymphoma was the cause in three patients, and disseminated cryptococcosis occurred in one patient. In the four other patients, chronic nonspecific peritonitis was found at laparoscopy; follow-up of these latter patients, including exploratory laparotomy in one patient and autopsy in two patients, disclosed no specific cause. Patients with the acquired immunodeficiency syndrome and high-protein ascites of uncertain etiology should undergo directed peritoneal evaluation as a potentially treatable disorder may be found. However, despite extensive evaluation, a subset of patients in whom no specific cause can be identified still remains.

Campylobacter-like organisms are uncommon pathogens in patients infected with the human immunodeficiency virus

Over a 25-month period, we prospectively evaluated 36 patients with symptomatic human immunodeficiency virus disease (including 27 with unexplained chronic diarrhea) by flexible sigmoidoscopy for the presence of Campylobacter-like organisms. No Campylobacter-like organisms were isolated. Campylobacter-like organisms appear to be an uncommon cause of idiopathic chronic diarrhea in symptomatic human immunodeficiency virus disease.

Cytomegalovirus-associated acute pancreatic disease in patients with acquired immunodeficiency syndrome. Report of two patients

Pancreatic disease has been infrequently reported in patients with acquired immunodeficiency syndrome. Over the last 3 years at our hospital, two patients with the acquired immunodeficiency syndrome and acute pancreatic or biliary disease, demonstrated at autopsy to be secondary to cytomegalovirus infection of the pancreas, have been evaluated. However, pancreatic disease was not recognized antemortem in our two patients because of their underlying diseases and the atypical presentation. Cytomegalovirus infection of the pancreas may cause acute symptomatic disease in patients with acquired immunodeficiency syndrome.

Utility of droperidol for conscious sedation in gastrointestinal endoscopic procedures

Although narcotics and benzodiazepines are widely used as premedications for gastrointestinal endoscopic procedures, we have found a significant number of patients in whom this combination is either inadequate for sedation or results in paradoxical agitation. Over the last 54 months, we have administered droperidol, a neuroleptic, as an adjunct to narcotics and benzodiazepines in 764 patients undergoing 1,102 procedures. The most common indication for droperidol usage was active alcohol abuse or withdrawal (45%). The most frequent dose administered was 2.5 mg (41.1%) followed by 3.75 mg (25.8%). The level of sedation and cooperation was adequate in all but 22 procedures (2.0%). Complications related to droperidol use were infrequent, occurring in 17 procedures (1.5%). There was no mortality or major morbidity resulting from droperidol usage. In our endoscopic population, we find droperidol to be a safe and efficacious adjunctive agent for conscious sedation.