Development and initial validation of an instrument for video-based assessment of technical skill in ERCP

BACKGROUND AND AIMS

The accurate measurement of technical skill in ERCP is essential for endoscopic training, quality assurance, and coaching of this procedure. Hypothesizing that technical skill can be measured by analysis of ERCP videos, we aimed to develop and validate a video-based ERCP skill assessment tool.

METHODS

Based on review of procedural videos, the task of ERCP was deconstructed into its basic components by an expert panel that developed an initial version of the Bethesda ERCP Skill Assessment Tool (BESAT). Subsequently, 2 modified Delphi panels and 3 validation exercises were conducted with the goal of iteratively refining the tool. Fully crossed generalizability studies investigated the contributions of assessors, ERCP performance, and technical elements to reliability.

RESULTS

Twenty-nine technical elements were initially generated from task deconstruction. Ultimately, after iterative refinement, the tool comprised 6 technical elements and 11 subelements. The developmental process achieved consistent improvements in the performance characteristics of the tool with every iteration. For the most recent version of the tool, BESAT-v4, the generalizability coefficient (a reliability index) was .67. Most variance in BESAT scores (43.55%) was attributed to differences in endoscopists' skill, indicating that the tool can reliably differentiate between endoscopists based on video analysis.

CONCLUSIONS

Video-based assessment of ERCP skill appears to be feasible with a novel instrument that demonstrates favorable validity evidence. Future steps include determining whether the tool can discriminate between endoscopists of varying experience levels and predict important outcomes in clinical practice.

Use of Appropriate Surveillance for Patients With Nondysplastic Barrett's Esophagus

BACKGROUND & AIMS

Barrett's esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC). Guidelines recommend that patients with nondysplastic BE (NDBE) undergo surveillance endoscopy every 3-5 years. We aimed to identify factors associated with surveillance endoscopy of patients with NDBE and identify trends in appropriate surveillance endoscopy of NDBE at a large tertiary care center.

METHODS

We performed a retrospective analysis of data from a Barrett's Esophagus Registry, identifying patients with NDBE who underwent endoscopy in 2002 or later. We identified patients with NDBE and collected data on length of BE segment, esophageal lesions, demographic features, medications, histology findings, comorbidities, development of EAC, and dates of follow-up endoscopies. We defined appropriate surveillance as 3-5 years between 2nd and 3rd endoscopies, over-utilizers as patients who had less than 3 years between their 2nd and 3rd endoscopies, under-utilizers as patients who had more than 5 years between their 2nd and 3rd endoscopies; and never-surveilled as patients who never received a 2nd endoscopy. The primary outcomes were effects of patient factors, year, and referring providers on appropriateness of surveillance intervals.

RESULTS

We identified 477 patients with NDBE. Only 15.9% had appropriate surveillance; 37.9% were over-utilizers 15.7% were under-utilizers and 30.4% were never surveilled. Patients were less likely to be over-surveilled if their primary care physician referred them for their 3rd endoscopy instead of a gastroenterologist (adjusted odds ratio, 0.51; 95% CI, 0.27-0.95). Male patients or those with an increased number of comorbidities were more likely to be under-surveilled or never-surveilled, whereas patients with long BE segment were more likely to be over-surveilled.

CONCLUSIONS

In a retrospective analysis of data from a registry of patients with BE, we found that less than 16% receive appropriate surveillance for NDBE. A primary care provider in the same health system as the endoscopy clinic reduced risk of over-surveillance. This could reflect better coordination of care between specialists and primary care providers.

Endoscopic suture fixation is associated with reduced migration of esophageal fully covered self-expandable metal stents (FCSEMS)

BACKGROUND

Esophageal fully covered self-expandable metal stents (FCSEMS) are indicated for the management of benign and malignant conditions of the esophagus including perforations, leaks, and strictures. FCSEMS are resistant to tissue ingrowth and are removable; however, stent migration occurs in 30-55% of cases. Endoscopic suture fixation of FCSEMS has been utilized to decrease the risk of stent migration though data supporting this practice remain limited. The primary aim of this study was to compare clinical outcomes and migration rate of patients who underwent placement of esophageal FCSEMS with and without endoscopic suture fixation.

METHODS

Our single-center, retrospective, cohort study includes patients who underwent esophageal FCSEMS placement with and without endoscopic suture fixation between January 1, 2012, and November 11, 2015. Baseline patient characteristics, procedural details, and clinical outcomes were abstracted. Logistic regression was performed to identify clinical and technical factors associated with outcomes and stent migration.

RESULTS

A total of 51 patients underwent 62 FCSEMS placements, including 21 procedures with endoscopic suture fixation and 41 without. Suture fixation was associated with reduced risk of stent migration (OR 0.13, 95% CI 0.03-0.47). Prior stent migration was associated with significantly higher risk of subsequent migration (OR 6.4, 95% CI 1.6-26.0). Stent migration was associated with lower likelihood of clinical success (OR 0.21, 95% CI 0.06-0.69). There was a trend toward higher clinical success among patients undergoing suture fixation (85.7 vs. 60.9%, p = 0.07).

CONCLUSIONS

Endoscopic suture fixation of FCSEMS was associated with a reduced stent migration rate. Appropriate patient selection for suture fixation of FCSEMS may lead to reduced migration in high-risk patients.

Effect of Covered Metallic Stents Compared With Plastic Stents on Benign Biliary Stricture Resolution: A Randomized Clinical Trial

IMPORTANCE

Endoscopic placement of multiple plastic stents in parallel is the first-line treatment for most benign biliary strictures; it is possible that fully covered, self-expandable metallic stents (cSEMS) may require fewer endoscopic retrograde cholangiopancreatography procedures (ERCPs) to achieve resolution.

OBJECTIVE

To assess whether use of cSEMS is noninferior to plastic stents with respect to stricture resolution.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter (8 endoscopic referral centers), open-label, parallel, randomized clinical trial involving patients with treatment-naive, benign biliary strictures (N = 112) due to orthotopic liver transplant (n = 73), chronic pancreatitis (n = 35), or postoperative injury (n = 4), who were enrolled between April 2011 and September 2014 (with follow-up ending October 2015). Patients with a bile duct diameter less than 6 mm and those with an intact gallbladder in whom the cystic duct would be overlapped by a cSEMS were excluded.

INTERVENTIONS

Patients (N = 112) were randomized to receive multiple plastic stents or a single cSEMS, stratified by stricture etiology and with endoscopic reassessment for resolution every 3 months (plastic stents) or every 6 months (cSEMS). Patients were followed up for 12 months after stricture resolution to assess for recurrence.

MAIN OUTCOMES AND MEASURES

Primary outcome was stricture resolution after no more than 12 months of endoscopic therapy. The sample size was estimated based on the noninferiority of cSEMS to plastic stents, with a noninferiority margin of -15%.

RESULTS

There were 55 patients in the plastic stent group (mean [SD] age, 57 [11] years; 17 women [31%]) and 57 patients in the cSEMS group (mean [SD] age, 55 [10] years; 19 women [33%]). Compared with plastic stents (41/48, 85.4%), the cSEMS resolution rate was 50 of 54 patients (92.6%), with a rate difference of 7.2% (1-sided 95% CI, -3.0% to ∞; P < .001). Given the prespecified noninferiority margin of -15%, the null hypothesis that cSEMS is less effective than plastic stents was rejected. The mean number of ERCPs to achieve resolution was lower for cSEMS (2.14) vs plastic (3.24; mean difference, 1.10; 95% CI, 0.74 to 1.46; P < .001).

CONCLUSIONS AND RELEVANCE

Among patients with benign biliary strictures and a bile duct diameter 6 mm or more in whom the covered metallic stent would not overlap the cystic duct, cSEMS were not inferior to multiple plastic stents after 12 months in achieving stricture resolution. Metallic stents should be considered an appropriate option in patients such as these.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01221311.

Status of Competency-Based Medical Education in Endoscopy Training: A Nationwide Survey of US ACGME-Accredited Gastroenterology Training Programs

OBJECTIVES

The Accreditation Council for Graduate Medical Education (ACGME) emphasizes the importance of medical trainees meeting specific performance benchmarks and demonstrating readiness for unsupervised practice. The aim of this study was to examine the readiness of Gastroenterology (GI) fellowship programs for competency-based evaluation in endoscopic procedural training.

METHODS

ACGME-accredited GI program directors (PDs) and GI trainees nationwide completed an online survey of domains relevant to endoscopy training and competency assessment. Participants were queried about current methods and perceived quality of endoscopy training and assessment of competence. Participants were also queried about factors deemed important in endoscopy competence assessment. Five-point Likert items were analyzed as continuous variables by an independent t-test and χ(2)-test was used for comparison of proportions.

RESULTS

Survey response rate was 64% (94/148) for PDs and 47% (546/1,167) for trainees. Twenty-three percent of surveyed PDs reported that they do not have a formal endoscopy curriculum. PDs placed less importance (1—very important to 5—very unimportant) on endoscopy volume (1.57 vs. 1.18, P<0.001), adenoma detection rate (2.00 vs. 1.53, P<0.001), and withdrawal times (1.96 vs. 1.68, P=0.009) in determining endoscopy competence compared with trainees. A majority of PDs report that competence is assessed by procedure volume (85%) and teaching attending evaluations (96%). Only a minority of programs use skills assessment tools (30%) or specific quality metrics (28%). Specific competencies are mostly assessed by individual teaching attending feedback as opposed to official documentation or feedback from a PD. PDs rate the overall quality of their endoscopy training and assessment of competence as better than overall ratings by trainees.

CONCLUSIONS

Although the majority of PDs and trainees nationwide believe that measuring specific metrics is important in determining endoscopy competence, most programs still rely on procedure volume and subjective attending evaluations to determine overall competence. As medical training transitions from an apprenticeship model to competency-based education, there is a need for improved endoscopy curricula which are better suited to demonstrate readiness for unsupervised practice.

Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial

IMPORTANCE

Abdominal pain after cholecystectomy is common and may be attributed to sphincter of Oddi dysfunction. Management often involves endoscopic retrograde cholangiopancreatography (ERCP) with manometry and sphincterotomy.

OBJECTIVE

To determine whether endoscopic sphincterotomy reduces pain and whether sphincter manometric pressure is predictive of pain relief.

DESIGN, SETTING, AND PATIENTS

Multicenter, sham-controlled, randomized trial involving 214 patients with pain after cholecystectomy without significant abnormalities on imaging or laboratory studies, and no prior sphincter treatment or pancreatitis randomly assigned (August 6, 2008-March 23, 2012) to undergo sphincterotomy or sham therapy at 7 referral medical centers. One-year follow-up was blinded. The final follow-up visit was March 21, 2013.

INTERVENTIONS

After ERCP, patients were randomized 2:1 to sphincterotomy (n = 141) or sham (n = 73) irrespective of manometry findings. Those randomized to sphincterotomy with elevated pancreatic sphincter pressures were randomized again (1:1) to biliary or to both biliary and pancreatic sphincterotomies. Seventy-two were entered into an observational study with conventional ERCP managemeny.

MAIN OUTCOMES AND MEASURES

Success of treatment was defined as less than 6 days of disability due to pain in the prior 90 days both at months 9 and 12 after randomization, with no narcotic use and no further sphincter intervention.

RESULTS

Twenty-seven patients (37%; 95% CI, 25.9%-48.1%) in the sham treatment group vs 32 (23%; 95% CI, 15.8%-29.6%) in the sphincterotomy group experienced successful treatment (adjusted risk difference, -15.6%; 95% CI, -28.0% to -3.3%; P = .01). Of the patients with pancreatic sphincter hypertension, 14 (30%; 95% CI, 16.7%-42.9%) who underwent dual sphincterotomy and 10 (20%; 95% CI, 8.7%-30.5%) who underwent biliary sphincterotomy alone experienced successful treatment. Thirty-seven treated patients (26%; 95% CI,19%-34%) and 25 patients (34%; 95% CI, 23%-45%) in the sham group underwent repeat ERCP interventions (P = .22). Manometry results were not associated with the outcome. No clinical subgroups appeared to benefit from sphincterotomy more than others. Pancreatitis occurred in 15 patients (11%) after primary sphincterotomies and in 11 patients (15%) in the sham group. Of the nonrandomized patients in the observational study group, 5 (24%; 95% CI, 6%-42%) who underwent biliary sphincterotomy, 12 (31%; 95% CI, 16%-45%) who underwent dual sphincterotomy, and 2 (17%; 95% CI, 0%-38%) who did not undergo sphincterotomy had successful treatment.

CONCLUSIONS AND RELEVANCE

In patients with abdominal pain after cholecystectomy undergoing ERCP with manometry, sphincterotomy vs sham did not reduce disability due to pain. These findings do not support ERCP and sphincterotomy for these patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00688662.

Colorectal cancer screening compliance and contemplation in gynecology patients

OBJECTIVE

Colorectal cancer screening (CRCS) should be a necessary part of gynecology (GYN) providers' preventive practices. The purpose of our study is to examine CRCS recommendations and adherence in this population.

METHODS

A questionnaire was administered to a prospective cohort of patients awaiting health maintenance exams at six academic and private gynecology offices. Patients reported demographics, CRC/breast/cervical screening adherence, CRCS recommendations, and future likelihood of CRCS.

RESULTS

A total of 461 women aged 51 years and older completed the questionnaire. Sixty-six percent of respondents were compliant with CRCS compared to 93% and 86% for breast and cervical cancer screening, respectively (p < 0.001). GYN providers recommended CRCS in 43% of patients. Sixty-three percent were planning to undergo future CRCS. On multivariable analysis, characteristics associated with CRCS adherence included (odds ratio, 95% confidence interval): older age (1.1 per year, 1.1-1.2), previous mammography (3.7, 1.4-9.7), family history (FH) of CRC/polyps (1.9, 1.0-3.4), friend with CRC (2.6, 1.5-4.7), and any doctor recommending CRCS (8.2, 4.6-14.7). CRCS rates were higher among patients who received a recommendation from a PCP (primary care provider) than from a GYN provider. Factors associated with intention to undergo CRCS include previous mammography (1.4, 4.2-12.0), any doctor recommendation (6.4, 3.7-11.0), and FH of CRC/polyps (3.5, 1.9-6.3). CRCS recommendations by both GYNs and PCPs had a greater impact on CRCS contemplation than those from a PCP or GYN alone.

CONCLUSION

In gynecology patients, having multiple providers recommend CRCS increases the likelihood of patients' intentions to undergo CRCS. However, CRCS compliance is primarily driven solely by PCP recommendations. Regardless, strategies must be in place to prompt gynecologists and nurse practitioners to discuss CRCS in eligible patients.

Quality assurance of training

Over the last decade there have been significant improvements in the standards of training across both the UK and US. Improvements in the UK have been catalysed by the need for high quality colonoscopy within the bowel cancer screening programme. In both the UK and US, central organisations now oversee the quality of endoscopic training and ensure that training standards are being met. Improvements in patient care are at the centre of quality assurance of training. Better training results in better doctors who provide better care for patients resulting in better patient outcomes.

Does colonoscopy cause increased ulcerative colitis symptoms?

BACKGROUND

Ulcerative colitis (UC) patients often report symptom flares after colonoscopy. However, this has not been documented in the literature.

OBJECTIVES

1. Determine whether colonoscopy is associated with increased UC symptoms. 2. Determine whether there is a need for escalation of UC medications after colonoscopy. 3. Identify baseline variables associated with increased symptoms after colonoscopy.

METHODS

Fifty-five outpatients with a history of UC, intact colon, and quiescent disease were enrolled in a prospective case-crossover study. Subjects were evaluated with the Simple Clinical Colitis Activity Index (SCCAI) before colonoscopy, 1 week and 4 weeks after colonoscopy. A mixed model analysis was used to accommodate nonindependence of repeated measurements on the same patients.

RESULTS

Fifty-one (91%) subjects completed the study. Six subjects had clinical relapse defined by a score of 5 or greater on the SCCAI during the week after colonoscopy. Five subjects increased their 5-aminosalicylic acid (5-ASA) medications immediately postcolonoscopy, two of whom had a SCCAI 5 or greater. Multivariate modeling demonstrated a clear association between the week immediately after colonoscopy preparation and increased disease activity, with the time period being predictive of increased SCCAI (week 1 vs. week 4, P = 0.0127). The baseline SCCAI (P value < 0.0001) and prednisone use (P = 0.0120) were predictive of increased SCCAI postcolonoscopy. Thiopurines (P < 0.001) were protective against increased symptoms.

CONCLUSIONS

In our study, 1 in 8 subjects had UC relapse by SCCAI immediately postcolonoscopy, and 1 in 10 subjects required an increase in their 5-ASA medications. Clinicians should be cognizant of this effect of colonoscopy in patients with UC.

A survey of physician practices on prophylactic pancreatic stents

BACKGROUND

Several prospective studies confirm that prophylactic stent placement in the pancreatic duct (PD) during high-risk ERCP procedures decreases the risk of post-ERCP pancreatitis. Inconsistencies exist regarding the indications for prophylactic PD stent placement, the type of stent used, and stent follow-up.

OBJECTIVE

To assess the current practice patterns of expert biliary endoscopists regarding prophylactic pancreatic duct stents.

DESIGN

An anonymous survey was mailed to 54 expert biliary endoscopists, assessing volume of procedures, stent indications, method of placement, and follow-up.

RESULTS

A total of 91% (49/54) of surveys were returned and analyzed. Prophylactic PD stents were used by 96% of respondents. Stent use was universal during ampullectomy and pancreatic sphincterotomy. Most also used stents for minor papillotomy (93%) and sphincter of Oddi dysfunction (SOD) confirmed by manometry (82%). Endoscopists disagreed on the following: pre-cut sphincterotomy (71%), prior post-ERCP pancreatitis (64%), suspected SOD (58-69%), and traumatic sphincterotomy (44%). Endoscopists used straight stents (33%), pigtail stents (30%), or a combination (33%). Internal flanges were always used by 14%, never used by 54%, and sometimes used by 32%. Stent size and length varied widely, as did the time stents were left in place, and the retrieval method.

CONCLUSIONS

Expert biliary endoscopists agree that prophylactic PD stenting is indicated during ERCP in high-risk patients. Wide variation exists in patient selection and stent placement technique.

Endoscopic retrograde cholangiopancreatography during pregnancy

Physiologic changes of pregnancy leave women at increased risk for gallstone complications. Endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy was first reported in 1990 for the treatment of complicated gallstone disease. Since then, numerous reports have shown that if certain precautionary measures are taken, therapeutic ERCP can be safely performed during pregnancy. A multidisciplinary approach that involves obstetrics, surgery, and gastroenterology is necessary to help ensure maternal and fetal safety. This article addresses the physiologic changes that increase a women's risk for gallstone complications, the indications for ERCP, the safety of ERCP, and its use within the last 15 years.

Botulinum toxin injection after biliary sphincterotomy

BACKGROUND AND STUDY AIMS

Endoscopic biliary sphincterotomy in patients with sphincter of Oddi dysfunction (SOD) is associated with a high risk of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP), which may be secondary to residual pancreatic sphincter hypertension. It was hypothesized that botulinum toxin injection could be used to reduce pancreatic sphincter hypertension temporarily in SOD patients after biliary sphincterotomy, thereby reducing the rate of procedure-induced pancreatitis.

PATIENTS AND METHODS

All patients undergoing ERCP with manometry due to a suspected biliary SOD were asked to participate in the study. Patients with elevated basal sphincter pressures were randomly assigned to receive either botulinum toxin or a sham saline injection after biliary sphincterotomy. Fifty units of botulinum toxin were delivered via a sclerotherapy needle in the form of two 25-U injections of 0.25 ml each into the pancreatic sphincter. In patients in the sham arm, 0.50 ml of saline was injected into the duodenal lumen.

RESULTS

Between 12 February 1999 and 29 November 2000, a total of 98 patients were referred for ERCP with manometry; 86 consented to participate in the study, and 26 had elevated baseline pressures and underwent random assignment. Twelve received botulinum toxin injection and 14 were randomly assigned to receive the sham injection. A total of six patients in the sham group (43 %) developed procedure-induced pancreatitis, compared with three patients in the botulinum toxin group (25 %; P = 0.34).

CONCLUSIONS

Biliary sphincterotomy in patients with sphincter of Oddi dysfunction without pancreatic protection is risky and should no longer be carried out. This study demonstrates that botulinum toxin injection into the residual pancreatic sphincter after biliary sphincterotomy is technically feasible and safe, showing a trend toward a reduced post-ERCP pancreatitis rate in patients with sphincter of Oddi dysfunction. Further studies will need to confirm the validity of these experimental results before this technique can be used routinely.

First cut, then blend: an electrocautery technique affecting bleeding at sphincterotomy

BACKGROUND AND STUDY AIMS

The use of pure cut electrocautery current for endoscopic sphincterotomy lowers pancreatitis rates following endoscopic retrograde cholangiopancreatography (ERCP), but at the expense of greater localized bleeding which partially obscures the endoscopic view. We hypothesized that localized bleeding could be decreased by using blended current at the end of the sphincterotomy, without losing the benefit associated with pure cut current of lower post-ERCP pancreatitis benefit.

PATIENTS AND METHODS

Patients undergoing sphincterotomy were randomly allocated to receive pure cut current alone or a sequential combination of pure cut then blended current. In the sequential combination patients, the first 75 - 80 % of the sphincterotomy was done using pure cut current at 30 W and the remainder completed at a blend 2 setting (pure cut plus coagulation current), also at 30 W.

RESULTS

142 patients were enrolled in the study. No statistical difference was noted between the two groups in the rates of overall pancreatitis or bleeding requiring transfusion. When comparing visible bleeding rates (more than a few drops), we found that there was significantly more bleeding (P < 0.05) in the pure cut group (31/75, 41 %) at the time of sphincterotomy compared with the sequential combination group (16/67, 23 %).

CONCLUSIONS

A sequential combination of pure cut and blended current for sphincterotomy caused less visible bleeding than pure cut alone. This occurred without a change in the rate of post-ERCP pancreatitis.

Acute cytomegalovirus infection complicated by vascular thrombosis: a case report

We present a case report of a previously healthy adult with cytomegalovirus infection that was complicated by extensive mesenteric arterial and venous thrombosis. To our knowledge, this is the first reported case of this syndrome in an immunocompetent individual who had no predisposing risk factors for thrombosis, and it demonstrates the propensity for cytomegalovirus to be involved in vascular disease.

The accuracy of EUS and helical CT in the assessment of vascular invasion by peripapillary malignancy

BACKGROUND

The relative accuracy of helical CT and EUS for defining the local resectability of peripapillary malignancies is undefined.

METHODS

Fifty-one patients with a peripapillary malignancy and no metastatic disease were prospectively evaluated with helical CT and EUS. Imaging results were compared with surgical staging, and a tumor was defined as resectable when there was no macroscopic or microscopic residual tumor.

RESULTS

Nine patients had surgically confirmed locally unresectable disease, which was accurately predicted by EUS in 6 patients (sensitivity 67%) and by helical CT in 3 patients (sensitivity 33%; p = 0.35). When only patients with complete EUS examinations were included, the sensitivities of EUS and helical CT for vascular invasion were 100% and 33% (p = 0.06), respectively. When all patients not undergoing surgery because of imaging evidence of locally unresectable disease were included, the sensitivities were 100% and 62.5% (p = 0.02), respectively. One of 15 patients with a tumor amenable to surgical resection was labeled as unresectable by EUS but subsequently had a local recurrence of the tumor. The specificities of EUS (93%) and helical CT (100%) were similar.

CONCLUSION

EUS is more sensitive than helical CT for detecting vascular invasion by peripapillary malignancies and should be added to staging protocols, particularly when findings on helical CT are equivocal.

Extracorporeal lithotripsy. An important adjunct in the nonoperative management of retained or recurrent bile duct stones

Retained or recurrent bile duct stones can be successfully removed in up to 80% to 85% of patients with the use of percutaneous or endoscopic techniques. However, problems related to difficult biliary access, large stones, and biliary strictures may decrease the success rate of this approach. We evaluated the safety and efficacy of extracorporeal shock-wave lithotripsy (ESWL) in 16 patients with complicated biliary stones treated prospectively over a 24-month period. Successful stone fragmentation was achieved in 15 patients (94%) using a Dornier HM3 lithotripter (average of 2290 shocks at 22 kV). Three patients (19%) required a second ESWL treatment. Biliary clearance of stone fragments was spontaneous in seven (43%) of the patients and required additional treatment in eight (57%) of the patients. Complications from ESWL were minor and included transient hematuria and ecchymoses at the skin entry site. Extracorporeal shock-wave lithotripsy failed in one patient (6%) with a biliary stricture and surgery was required. At hospital discharge, all patients were asymptomatic and stone free. Treatment with ESWL appears to be a safe and effective adjunct for selected patients with complex biliary stone disease.

Colonic xanthomatosis. Relationship to disordered motility and review of the literature

We report two additional cases of colonic xanthomatosis associated with persistent rectal symptoms. Disordered colonic motility in the areas of lipid infiltration was documented in one patient. We conclude these lesions may have a pathophysiologic role in the alteration of intestinal motility which appears to be the cause of our patients' symptoms.

Endoscopic diagnosis of gastritis: causative factors in 100 patients

The frequency of gastritis in relation to its various predisposing conditions is unclear, as is the respective distribution of damage caused by its predisposing conditions. We studied 100 patients with the endoscopic diagnosis of gastritis. The incidence of gastritis in our university gastroenterology endoscopy service was 23%. A history of aspirin (ASA) or nonsteroidal anti-inflammatory drug (NSAID) use was present in 42%. No predisposing factors were found in 28% of cases. Stress gastritis was present in 10% of patients, all of whom were in the intensive care unit. Alcoholism, gastric resection, and portal hypertension were considered causative in 19%. Multiple predisposing factors were uncommon (3%). Coincident duodenal ulcer(s) and erosive duodenitis were common and were more frequent in the patients having idiopathic gastritis (46%) than in those who used ASA or NSAIDs (29%). The antrum was the portion of the stomach most frequently involved. This antral distribution of damage was predominant in both the ASA/NSAID-associated cases and in the idiopathic group. In contrast, patients with stress gastritis were more likely to have involvement of the gastric fundus and body.

Esophageal reflux and dysmotility as the basis for persistent cervical symptoms

To examine a possible esophageal basis for cervical symptoms, we studied 63 patients with persistent cervical complaints, 36 patients with gastroesophageal reflux but no cervical symptoms, and ten normal subjects. Patients were evaluated for a history of pyrosis and regurgitation and underwent otolaryngologic examination, barium esophagram, upper endoscopy, esophageal biopsy, standard esophageal manometrics, acid reflux testing, and Bernstein examination, as well as tests of esophageal dysmotility and acid clearance time before and after bethanechol (50 micrograms/kg, two doses). Standard diagnostic examinations usually were normal in patients with cervical symptoms. Pyrosis, regurgitation, and a positive Bernstein examination were uncommon in patients with cervical symptoms. This occurred despite frequent acid reflux (68%) and poor acid clearance (79%). Esophageal dysmotility also was common (63%). Patients with reflux but no cervical symptoms and normal subjects had a normal acid clearance time, and dysmotility was unusual (8%). We conclude that patients with cervical symptoms have diminished esophageal sensitivity despite frequent and long acid exposure. The pathophysiologic significance of this observation is discussed.

Biliary obstruction secondary to an extramedullary plasmacytoma of the pancreas: confusion with pancreatitis on computed tomography

A 29-year-old woman with a history of a maxillary plasmacytoma treated with radiation therapy presented with painless jaundice. A computed tomography (CT) scan revealed biliary dilatation and diffuse pancreatic enlargement suggestive of pancreatitis. Percutaneous transhepatic cholangiography demonstrated encasement of the distal common bile duct by an extrinsic mass. At exploratory laparotomy, a large mass replacing the entire pancreas was found. Pathologic examination confirmed plasmacytoma. This report presents a unique case of extramedullary plasmacytoma involving the pancreas early in a patient's clinical course. The CT appearance was similar to that of acute pancreatitis.

A submucosal antral mass caused by cytomegalovirus infection in a patient with acquired immunodeficiency syndrome

A 29-yr-old homosexual man with acquired immunodeficiency syndrome presented with watery diarrhea and fever. Upper gastrointestinal endoscopy was performed to obtain duodenal aspirates and biopsies. A 4-cm submucosal mass in the gastric antrum was identified. Subsequent abdominal CT scan confirmed the presence of this antral mass. An attempt at CT guided needle biopsy was nondiagnostic. Because the mass possibly represented a Kaposi's sarcoma or lymphoma, exploratory laparotomy and open biopsy was performed. Examination of the biopsy specimen showed inflammatory debris with multiple intranuclear cytomegalovirus inclusions. This report describes a case of a submucosal antral mass caused by localized cytomegalovirus infection in a patient with acquired immunodeficiency syndrome.

Ca2+ channel blockers stimulate ileal and colonic water absorption

The effects of calcium channel blockers on water transport in the rat ileum and distal colon were studied in vivo using the single-pass perfusion technique. Parenteral but not intraluminal verapamil, and parenteral nifedipine increased ileal water absorption, with effects lasting at least 60 min. In contrast, i.p. verapamil had no effect on rat distal colonic water absorption, whereas intraluminal verapamil significantly stimulated colonic water absorption. Similarly, perfusing the rat descending colon with low-Ca2+ Ringer's-HCO3 stimulated colonic water absorption. Verapamil was not antisecretory because the theophylline-induced decrease in ileal water transport was similar in control animals and in animals pretreated with i.p. verapamil. In addition, nifedipine stimulated active Na and Cl absorption in rabbit ileum. These studies demonstrate that the Ca2+ channel blockers verapamil and nifedipine stimulate basal absorption of water in rat ileum and distal colon in vivo, and stimulate active Na and Cl absorption in rabbit ileum in vitro. The verapamil stimulation of colonic water absorption from the luminal surface was duplicated by perfusion with a low-Ca2+ bathing solution. This suggests the presence of apical membrane Ca2+ channels in rat colon, which appear to be involved in regulation of basal water transport, and that these Ca2+ channels are in a partially open state under basal conditions. Because verapamil stimulates absorption systemically (ileum) as well as intraluminally (colon), Ca2+ channel blockers have properties that might be useful in treatment of diarrheal diseases.

Effect of dopamine and bromocriptine on rat ileal and colonic transport. Stimulation of absorption and reversal of cholera toxin-induced secretion

Water and electrolyte transport were determined in rat ileum and colon using the single-pass perfusion technique. Intraperitoneal dopamine caused prompt stimulation of both ileal and colonic water absorption. The dopamine effect was mediated by both specific dopamine and alpha 2-adrenergic receptors. Haloperidol, a specific dopamine antagonist, and yohimbine, an alpha 2-adrenergic antagonist, inhibited the effect of dopamine in ileal absorption; both antagonists alone had no effect on basal water transport. Bromocriptine (intravenous and intraluminal) stimulated ileal and colonic water absorption, which was inhibited by haloperidol and yohimbine, and reversed cholera toxin-induced ileal secretion. Magnitude and time-courses of the increased water absorption in ileal loops, inoculated with saline, were the same as in loops, inoculated with saline, suggesting that bromocriptine acted to reverse cholera toxin-induced secretion by stimulating absorption. Bromocriptine had no effect on the cyclic adenosine monophosphate increase caused by cholera toxin. We conclude (a) dopamine stimulates water absorption in vivo in rat ileum and colon; (b) this dopamine effect is via specific dopamine and alpha 2-receptors; (c) bromocriptine stimulates water absorption in ileum and colon and also acts by dopamine and alpha 2-receptors; and (d) bromocriptine reverses cholera toxin-induced secretion.

Trifluoperazine reversal of secretory diarrhea in pancreatic cholera

Diarrhea in a patient with pancreatic cholera syndrome caused by a vasoactive intestinal polypeptide producing pancreatic islet-cell carcinoma responded rapidly and dramatically to the phenothiazine trifluoperazine. Treatment with intravenous somatostatin decreased the plasma vasoactive intestinal polypeptide level without changing the diarrhea. The chemotherapeutic agent chlorozotocin, the 2-chloroethyl analogue of streptozocin, caused a decrease in plasma vasoactive intestinal polypeptide but caused significant renal toxicity with proteinuria.