An international, multi-institution survey of the use of EUS in the diagnosis of pancreatic cystic lesions

Background and Objectives:

Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field.

Methods:

A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized.

Results:

Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year.

Conclusion:

Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.

Practice guidelines for endoscopic ultrasound-guided celiac plexus neurolysis

Objectives:

The objective of guideline was to provide clear and relevant consensus statements to form a practical guideline for clinicians on the indications, optimal technique, safety and efficacy of endoscopic ultrasound guided celiac plexus neurolysis (EUS-CPN).

Methods:

Six important clinical questions were determined regarding EUS-CPN. Following a detailed literature review, 6 statements were proposed attempting to answer those questions. A group of expert endosonographers convened in Chicago, United States (May 2016), where the statements were presented and feedback provided. Subsequently a consensus group of 35 expert endosonographers voted based on their individual level of agreement. A strong recommendation required 80% voter agreement. The modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria were used to rate the strength of recommendations and the quality of evidence.

Results:

Eighty percent agreement was reached on 5 of 6 consensus statements, 79.4% agreement was reached on the remaining one.

Conclusions:

EUS-CPN is efficacious, should be integrated into the management of pancreas cancer pain, and can be considered early at the time of diagnosis of inoperable disease. Techniques may still vary based on operator experience. Serious complications exist, but are rare.

The presence of a cytopathologist increases the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration cytology for pancreatic adenocarcinoma: a meta-analysis

OBJECTIVE

A meta-analysis has not been previously performed to evaluate critically the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of solely pancreatic ductal adenocarcinoma and address factors that have an impact on variability of accuracy. The aim of this study was to determine whether the presence of a cytopathologist, variability of the reference standard and other sources of heterogeneity significantly impacts diagnostic accuracy.

METHODS

We conducted a comprehensive search to identify studies, in which the pooled sensitivity, specificity, likelihood ratios for a positive or negative test (LR+, LR-) and summary receiver-operating curves (SROC) could be determined for EUS-FNA of the pancreas for ductal adenocarcinoma using clinical follow-up, and/or surgical biopsy or excision as the reference standard.

RESULTS

We included 34 distinct studies (3644 patients) in which EUS-FNA for a solid pancreatic mass was evaluated. The pooled sensitivity and specificity for EUS-FNA for pancreatic ductal adenocarcinoma was 88.6% [95% confidence interval (CI): 87.2-89.9] and 99.3% (95% CI: 98.7-99.7), respectively. The LR+ and LR- were 33.46 (95% CI: 20.76-53.91) and 0.11 (95% CI: 0.08-0.16), respectively. The meta-regression model showed rapid on-site evaluation (ROSE) (P = 0.001) remained a significant determinant of EUS-FNA accuracy after correcting for study population number and reference standard.

CONCLUSION

EUS-FNA is an effective modality for diagnosing pancreatic ductal adencarcinoma in solid pancreatic lesions, with an increased diagnostic accuracy when using on-site cytopathology evaluation.

Transgastric endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with esophageal narrowing using the ultrasonic bronchovideoscope

Endobronchial ultrasound-guided fine needle aspiration (EBUS-FNA) is emerging as a critical technology in the evaluation of mediastinal lesions and is increasingly regarded as complementary to endoscopic ultrasound (EUS) in this arena. This complementary role may extend into the abdomen in cases where esophageal strictures prevent the passage of the echoendoscope. The objective of the study was to characterize the uses of EBUS-FNA in the evaluation of gastrointestinal lesions in patients with esophageal narrowing. The study design was a single-center case series. The setting was in a tertiary referral center. Four patients underwent EBUS-FNA to evaluate gastrointestinal lesions; esophageal strictures prevented EUS passage in three, the fourth patient did not tolerate transbronchial EBUS but had abdominal lesions within reach of the EBUS scope. EBUS was used to evaluate the liver, adrenal gland, a retroperitoneal mass, and a celiac axis lymph node. EBUS-FNA has greater potential to evaluate abdominal lesions than has been previously recognized. The EBUS scope represents a safe and readily available technology to evaluate patients with esophageal strictures. Interventional endoscopists should be exposed to this modality.

A pilot study of fully covered self-expandable metal stents prior to neoadjuvant therapy for locally advanced esophageal cancer

Self-expandable metal stents (SEMS) have been mostly reserved for palliation of dysphagia because of advanced esophageal cancer. Fully covered SEMS (FCSEMS) (ALIMAXX-E, Alveolus Inc, Charlotte, NC, USA) offer the choice of removability if complications occur or maximum therapeutic benefit is achieved. To our knowledge, their use has not been studied in patients undergoing neoadjuvant therapy. The objectives of this study were the following: (i) to evaluate whether FCSEMS are useful in patients receiving neoadjuvant therapy; and (ii) to assess ease of removability and tissue reaction to FCSEMS. FCSEMS (ALIMAXX-E, Alveolus Inc) were deployed in consecutive patients with locally advanced esophageal cancer over a period of 14 months. All patients were referred for neoadjuvant chemoradiation therapy after stenting. Dysphagia scores were assessed at 0 month, 1 month, 3 months, and 6 months. Barium swallow and endoscopy were performed for new symptoms and follow-up. Eleven patients were treated with FCSEMS prior to neoadjuvant therapy (mean age 60.5 years, 55% white, 91% male). All but one stent were successfully placed. Strictures were located in the upper esophagus (n= 1), middle esophagus (n= 4), lower esophagus (n= 2), and gastroesophageal junction (n= 4). Dysphagia was significantly improved at 1 month (mean difference 3.12; 2.53-3.79 95% confidence interval [CI]), 3 months (mean difference 2.86, 2.19-3.53 95% CI), and 6 months (mean difference 2.56, 1.79-3.34 95% CI) compared with baseline. Three patients (27%) experienced chest pain or heartburn immediately following deployment. Only two patients ultimately underwent surgical resection. The others were diagnosed with metastatic disease prior to surgery, had disease progression in spite of neoadjuvant treatment, or died with the stent in place. Three patients developed delayed complications: recurrent dysphagia (n= 2) and tracheal-esophageal fistula (n= 1). Eight (73%) stents were subsequently removed, one because of complication (tracheal-esophageal fistula), one because of migration (recurrent dysphagia), one was incorrectly deployed, and five were felt to have satisfied their purpose. Stents remained in place for a mean duration of 100.36 days (range 0-105, median 84). Removal was characterized as very easy in all cases. Upon removal, ulcerations at the proximal or distal edge of stents were noted in six patients (75%), polyps in four (50%), and granulation in six (75%). One stent (13%) became embedded but was easily lifted from tissue. There were no perforations. Neoadjuvant treatment may have contributed to improvement in dysphagia scores. FCSEMS can be used to re-establish esophageal luminal patency in patients undergoing neoadjuvant therapy for locally advanced esophageal cancer, resulting in significant improvement in dysphagia over baseline. Tissue reaction to stents occurs but does not appear to impair removability.

Endoscopic evaluation and treatment of esophageal cance

Esophageal cancer is the sixth leading cause of cancer mortality. During the past twenty years the prevalence of adenocarcinoma, which is linked to gastroesophageal reflux and Barrett's metaplasia, has increased precipitously for unclear reasons. Endoscopic ultrasound (EUS) has revolutionized primary tumor (T) and nodal (N) staging. Additionally, the recent introduction of combined computed and positron emission tomography (CT-PET) promises to improve the detection of distant metastasis. While classic surgical approaches have significant morbidity and mortality, the recent widespread introduction of minimally invasive techniques including endoscopic mucosal resection and radiofrequency ablation offer new options to those with limited disease. Finally, endoscopically placed self expandable metal stents have become the primary mode of palliating dysphagia and there is a growing interest in the use of removable stents to optimize nutrition in neoadjuvant chemotherapy patients awaiting esophagectomy. In this article we will review the presentation, staging, and treatment of esophageal cancer with an emphasis on the evolving role of endoscopy to help accomplish these objectives.

Prospective randomized trial evaluating ketamine for advanced endoscopic procedures in difficult to sedate patients

BACKGROUND

Adequate patient sedation is mandatory for advanced endoscopic procedures such as ERCP and EUS.

AIM

To evaluate the effectiveness and safety of ketamine in difficult to sedate patients undergoing advanced endoscopic procedures.

METHODS

This was a prospective, randomized trial of all patients undergoing ERCP or EUS who were not adequately sedated despite administration of meperidine 50 mg, midazolam 5 mg and diazepam 5 mg. Patients during endoscopy were then randomized to receive either intravenous ketamine (20 mg) every 5 min or continue to receive standard sedation using meperidine and diazepam.

RESULTS

Of 175 patients, 82 were randomized to receive ketamine and 93 standard sedatives. Compared with standard sedation, qualitative physician rating (P < 0.0001) and depth of sedation (P < 0.001) were superior in the ketamine group with shorter recovery times (P < 0.0001). Both patient discomfort and sedation-related technical difficulty were significantly less among patients randomized to receive ketamine (P < 0.0001). More patients in the standard sedation group were crossed-over to the ketamine group due to sedation failure (35.5 vs. 3.7%, P < 0.0001). Nine patients who received ketamine, developed adverse events that were managed conservatively.

CONCLUSIONS

Ketamine is a useful adjunct to conscious sedation in patients who are difficult to sedate. Its use Results in better quality and depth of sedation with shorter recovery times than patients sedated using benzodiazepines and meperidine alone. Further prospective studies evaluating the effectiveness and safety of ketamine for endoscopic sedation are needed.

Cumulative sum procedure in evaluation of EUS-guided FNA cytology: the learning curve and diagnostic performance beyond sensitivity and specificity

BACKGROUND

Using cumulative sum (CUSUM) chart, we address two questions: (i) Over time, how will an EUS-FNA (endoscopic ultrasound guided fine needle aspiration) service maintain an acceptable non-diagnostic rate defined as technical failures, unsatisfactory specimens and atypical and suspicious diagnoses? (ii) Over time, how will EUS-FNA maintain acceptable diagnostic errors (false-positives plus false-negative diagnosis)?

METHODS

The study included all consecutive patients who underwent EUS-FNA at our institution from July 2000 to October 2003 and were followed up until December 2004. Using a simple spread sheet, we designed CUSUM charts and used them to track trends and assess performance at a preset acceptable rate of 10% and a preset unacceptable rate of 15% for non-diagnostic rate and diagnostic errors. We assessed all cases collectively and then in groups defined by site, size and cytopathologist.

RESULTS

Of 876 patients undergoing EUS-FNA, 83 (9.5%) had non-diagnostic results: 43 (51%) of these diagnoses were 'atypical', 27(33%) were 'suspicious for malignancy', eight (10%) were 'insufficient material for diagnosis' and five (6%) were 'technical failure'. In 585 cases with adequate follow up, there were 26 (6.3%) diagnostic errors: three (0.5%) were false positive and 23 (3.1) were false negative. The overall CUSUM charts for both non-diagnostic rate and for diagnostic error rate start with a small period of learning then cross to a significantly acceptable level at case numbers 121 and 97 respectively. Our diagnostic performance was better in lymph nodes than in the pancreas and other organs and was not significantly different for lesions <or=25 mm compared with lesion >25 mm in diameter. Performance was better for pathologists with prior experience than for pathologists without experience.

CONCLUSION

In the current climate of proficiency testing, error tracking and competence evaluation, there is a great potential for the use of CUSUM charts to assess procedure failure and error tracking in quality control programs, particularly when a new procedure such as EUS-FNA is introduced in the laboratory. Additionally, the method can be used to assess trainee competency and to track the proficiency of practicing cytologists.

Transgastric endoscopic ultrasound-guided fine-needle aspiration biopsy and flow cytometry of suspected lymphoma of the spleen

BACKGROUND AND STUDY AIMS

Masses in the spleen can be sampled by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) but the diagnosis of lymphoma using EUS-FNA and flow cytometry has not been reported. We report our experience with transgastric EUS-FNA and flow cytometry in the investigation of patients with suspected lymphoma of the spleen.

PATIENTS AND METHODS

All patients with splenic lesions that had been detected by computed tomography and who were referred for transgastric EUS-FNA over a 3-year period were enrolled in this study. The tissue obtained by EUS-FNA was evaluated by flow cytometry in all patients.

RESULTS

Six patients with splenic masses were enrolled (four men, two women; median age 58.5 years, range 41 - 82 years). The mean size of the short axis of the lesions was 37.8 mm (SD 23.76 mm) and the mean size of the long axis was 45.6 mm (SD 31.72 mm). EUS-FNA was performed successfully in all patients and the tissue obtained was evaluated by flow cytometry. Two patients were diagnosed with lymphoma; no pathology was identified in the other four patients. Lymphoma of the spleen appeared as sharply demarcated echo-poor lesions; benign lesions appeared echo-rich in comparison with the surrounding splenic tissue. The two patients who were diagnosed with lymphoma underwent chemotherapy. Of the four patients in whom no pathology was identified, one patient subsequently underwent splenectomy for evaluation of persistent abdominal pain and was diagnosed with lymphoma; the three other patients had true-negative disease on the evidence of long-term follow-up (mean 8 months; range 6 - 12 months). No complications related to the EUS-FNA procedure were encountered in any patient.

CONCLUSIONS

EUS-FNA of spleen masses is a safe technique that aids in the diagnosis of lymphoma when used in conjunction with flow cytometry.

Do all patients with abnormal intraoperative cholangiogram merit endoscopic retrograde cholangiopancreatography?

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used for postoperative evaluation of an abnormal intraoperative cholangiogram (IOC). Although a normal IOC is very suggestive of a disease-free common bile duct (CBD), abnormal studies are associated with high false-positive rates. This study aimed to identify a subset of patients with abnormal IOC who would benefit from a postoperative ERCP.

METHODS

This prospective study investigated 51 patients with abnormal IOC at laparoscopic cholecystectomy who underwent postoperative ERCP at two tertiary referral centers over a 3-year period. Univariate and multivariate logistic regression analyses were performed to determine predictors of CBD stones at postoperative ERCP.

RESULTS

For all 51 patients, ERCP was successful. The ERCP showed CBD stones in 33 cases (64.7%), and normal results in 18 cases (35.2%). On univariate analysis, abnormal liver function tests (p < 0.0001) as well as IOC findings of a large CBD stone (p = 0.03), multiple stones (p = 0.01), and a dilated CBD (p = 0.07) predicted the presence of retained stones at postoperative ERCP. However, on multivariable analysis, only abnormal liver function tests correlated with the presence of CBD stones (p < 0.0001).

CONCLUSIONS

One-third of patients with an abnormal IOC have a normal postoperative ERCP. Elevated liver function tests can help to identify patients who merit further evaluation by ERCP. The use of less invasive methods such as endoscopic ultrasound or magnetic resonance cholangiopancreatography should be considered for patients with normal liver function tests to minimize unnecessary ERCPs.

Endoscopic ultrasound-guided FNA biopsy of bile duct and gallbladder: analysis of 53 cases

OBJECTIVE

Endoscopic retrograde cholangiopancreaticography (ERCP)-guided brushing has been the standard of practice for surveillance and detection of carcinoma in the biliary tree. Few studies have evaluated the role of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in diagnosing clinically suspected cholangiocarcinoma. The role of this method in diagnosing clinically suspected gallbladder malignancies has not been extensively evaluated in the USA. This study investigates the role of EUS-FNA in the diagnosis of clinically suspected biliary tree and gallbladder malignancies in a large patient series.

METHODS

EUS-FNAs were obtained from 46 bile duct and seven gallbladder lesions. On-site rapid interpretation was provided using air-dried Diff Quik stained smears. In addition, alcohol fixed Papanicoloau stained smears and Thin Prep preparations (Cytye Corp., Marlborough, MA, USA) were evaluated before providing a final cytological diagnosis. Tissue biopsies and/or clinical follow-up were used as the standards to determine operating characteristics for EUS-FNA.

RESULTS

The mean ages for bile duct and gallbladder lesions were 66 years (range: 37-84 years), and 69 years (range 49-86 years), respectively. All cases diagnosed as suspicious/malignant on preliminary evaluation were confirmed on final cytological interpretation (27/27). The operating characteristics show that EUS-FNA is highly specific (100%) with sensitivity rates of 87% and 80% from clinically suspected malignancies of biliary tract and gallbladder, respectively. Sampling error in three cases and associated acute inflammation in two cases resulted in false-negative diagnoses.

CONCLUSIONS

EUS-FNA of biliary tree and gallbladder carcinoma is highly specific and should be considered for evaluation of clinically suspicious lesions. Marked inflammation may result in false-negative diagnoses.

Endoscopic ultrasound-guided fine-needle aspiration of intramural and extraintestinal mass lesions: diagnostic accuracy, complication assessment, and impact on management

BACKGROUND AND STUDY AIMS

The aims of this study were: firstly, to determine the usefulness of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in obtaining tissue diagnosis of intramural and extraintestinal lesions; secondly, to assess the immediate, acute, and 30-day complications in these patients; and thirdly, to assess the impact of the tissue diagnoses on patient management.

PATIENTS AND METHODS

All EUS-FNAs of extraintestinal mass lesions and intramural gastrointestinal tumors over a 26-month period were evaluated prospectively. The reference standards for the final diagnosis were surgery (n = 20), repeat imaging (n = 12), clinical follow-up (n = 4), or death from disease (n = 2). Four patients were lost to follow-up.

RESULTS

Forty-two consecutive patients (24 men, 18 women; mean age 59.7 years) underwent EUS-FNA of extraintestinal mass lesions and intramural gastrointestinal tumors. Previous attempts at tissue diagnosis had failed in 52.4 % of the patients. The EUS-FNA cytological diagnoses included: 17 gastrointestinal stromal tumors, five esophageal cancers, five rectal cancers, one bronchogenic cyst, one foregut duplication cyst, and 13 other miscellaneous diagnoses. The mean number of passes needed to reach a diagnosis was 3.9 (+/- 2.2). The mean follow-up period was 13.1 months. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA of extraintestinal and intramural tumors were 97 %, 100 %, 100 %, 90 %, and 98 %, respectively. No major complications were encountered.

CONCLUSIONS

EUS-FNA is a safe and accurate method that can provide a tissue diagnosis in intramural and extraintestinal mass lesions, especially when other modalities have failed. EUS-FNA significantly affects the management of patients by allowing them to be allocated to appropriate treatment and by avoiding the need for more invasive procedures to obtain tissue diagnosis.

Endoscopic ultrasound-guided fine-needle aspiration in the evaluation of gallbladder masses

BACKGROUND AND STUDY AIMS

There are very few data on endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of gallbladder masses. The aim of this study was to assess the utility and safety of EUS-FNA in the evaluation of patients with gallbladder masses.

PATIENTS AND METHODS

Six patients who underwent EUS-FNA of gallbladder masses over a 2-year period between 2002 and 2004 were studied retrospectively. Reports of endoscopic ultrasound (EUS) procedures, EUS images, cytology results, and clinical records were reviewed. Abdominal computed tomography (CT) prior to EUS had revealed a definitive gallbladder mass in only one of the six patients and no gallbladder masses were identified in any of the patients who had undergone prior transabdominal ultrasound.

RESULTS

At EUS, all the patients were found to have an echo-poor mass arising from the gallbladder wall or within the lumen of the gallbladder. EUS-FNA of the gallbladder masses revealed adenocarcinoma in five patients and benign disease in one patient. After a mean follow-up period of 127 days (range 90 - 187 days), three patients had died, two were undergoing palliative chemoradiotherapy, and one had been confirmed as having chronic cholecystitis at surgery. No complications occurred.

CONCLUSIONS

In patients with obstructive jaundice and equivocal ultrasound or CT findings, evaluation of the gallbladder for the presence of a primary malignancy by EUS is useful. In patients with gallbladder masses, EUS-FNA can be performed safely and can help to make a definitive diagnosis.

Prevalence and significance of periduodenal venous collaterals in patients evaluated for pancreaticobiliary disorders by endosonography

BACKGROUND AND STUDY AIMS

The prevalence of periduodenal venous collaterals detected by endoscopic ultrasonography (EUS) in patients undergoing evaluation for pancreaticobiliary disorders, and their influence on the success of transduodenal fine-needle aspiration (FNA) of solid pancreatic masses is not known.

PATIENTS AND METHODS

Records for all consecutive patients who underwent EUS for pancreaticobiliary disorders over a 14-month period were reviewed. EUS was carried out by a single endosonographer using a radial echo endoscope. When FNA was attempted, a curvilinear-array echo endoscope was used in conjunction with color flow Doppler. Periduodenal and perigastric collaterals were defined as multiple anechoic serpiginous structures imaged from the duodenal bulb, the second portion of duodenum, or the stomach. Established criteria were used to assess the presence of chronic pancreatitis.

RESULTS

Over the study period, 338 patients (mean age 58.9 +/- 14.5 years; 52 % women) underwent EUS for pancreaticobiliary disorders. Periduodenal collaterals were detected in 22 patients (6.5 %), 21 of whom (19 %) had pancreatic cancer. Patients with pancreatic cancer were significantly more likely to have periduodenal collaterals in comparison with those without pancreatic cancer (OR 25; 95 %CI, 5.75 - 109; P = 0.001). Computed tomography detected collaterals in only two of the 22 patients (9.1 %). Periduodenal collaterals made transduodenal FNA impossible in nine of the 22 patients (41 %). However, in these patients a cancer diagnosis was obtained using EUS-FNA from liver lesions in two cases; using a transgastric approach in two (pancreatic neck lesions); and atypical cells were obtained in two. A safe window could not be achieved in three patients (13.6 %). Transduodenal FNA was performed by avoiding the collaterals and was successful in 13 of the 22 patients, with no bleeding complications.

CONCLUSIONS

Periduodenal collateral vessels are infrequent in patients with suspected pancreaticobiliary disease, but are relatively common in patients with pancreatic cancer. Transduodenal EUS-FNA can be carried out safely in the majority of cases in the presence of periduodenal collaterals, but collaterals may occasionally hamper successful transduodenal pancreatic FNA.

Predictors of successful clinical and laboratory outcomes in patients with primary sclerosing cholangitis undergoing endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with primary sclerosing cholangitis (PSC) can be a challenging and sometimes gratifying opportunity for therapeutic intervention. Although there often appears to be initial radiological improvement after ERCP, the benefit as measured by serial estimations of subsequent liver enzymes is questionable. The fluctuating course of the inflammatory process makes the interpretation of serology even more difficult.

OBJECTIVES

To document and compare the liver profile and clinical status of patients before and after diagnostic and therapeutic ERCP; to determine predictors of clinical and laboratory success in patients with PSC; and to assess the complication rate of diagnostic and therapeutic ERCP in these patients.

METHODS

All patients with PSC who underwent ERCP at the authors' medical centres between January 6, 1987 and January 12, 1998 were identified using a computerized database. Presenting symptoms, liver enzymes (aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase) and bilirubin were recorded before ERCP. Clinical success was defined as resolution of the presenting symptoms. Laboratory success was defined as improvement in two of three liver enzymes by at least 50%, or resolution of jaundice.

RESULTS

One hundred four patients underwent 204 ERCPs of which 56 ERCPs were diagnostic. Clinical improvement was seen in 35% of the patients after diagnostic ERCP and in 70% after therapeutic procedures (chi 2=18.4, P=0.001). Laboratory improvement was seen in 35% of patients undergoing diagnostic ERCP and in 52% of the patients undergoing therapeutic ERCP (P=0.04). The reductions in liver enzymes were significant in both the diagnostic and therapeutic groups. Serum bilirubin level decreased significantly in the therapeutic ERCP group only. In a univariate analysis, patients with common bile duct strictures, any dominant stricture and those who underwent a therapeutic procedure were most likely to have clinical and laboratory improvement. In multivariable logistic regression, the presence of a dominant stricture, endoscopic therapy and high serum bilirubin were all independent predictors of a successful clinical outcome. There was no difference in total complication rates (18% versus 14%) when comparing the diagnostic and therapeutic ERCP groups. However, all seven severe complications occurred in the therapeutic ERCP group.

CONCLUSIONS

First, in PSC, clinical and laboratory improvement is more common in patients undergoing therapeutic ERCP than diagnostic ERCP. Second, aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase improve following both diagnostic and therapeutic ERCP, and should therefore not be relied upon to determine the success of the procedure. Third, bilirubin levels decreased in the therapeutic group but remained unchanged in the diagnostic group, suggesting that the serum bilirubin level may be a more sensitive indicator of successful therapeutic intervention than transaminases. Fourth, common bile duct strictures, dominant strictures and bilirubin levels are important variables in determining the success of an ERCP in PSC. Finally, complication rates after therapeutic ERCP are similar to those after diagnostic ERCP in PSC patients. However, severe complications occur more commonly in the therapeutic group.

ERCP-related perforations: risk factors and management

BACKGROUND AND STUDY AIMS

Perforations during endoscopic retrograde cholangiopancreatography (ERCP) are rare, and the management of these perforations is variable, with some patients requiring immediate surgery and others only conservative management. We reviewed all ERCP-related perforations at our institution to determine: a) their incidence; b) clinical outcomes; c) which management approaches gave the best results; and d) which factors predict a perforation.

PATIENTS AND METHODS

All patients who underwent ERCP and suffered perforation were reviewed. To compare the length of hospital stay of the perforation group with that of patients suffering a different complication, patients who developed post-ERCP pancreatitis were also reviewed. To evaluate predictors of ERCP-related perforations, three groups were compared: group 1 (n = 49), normal ERCP/no complications; group 2 (n = 52), ERCP complicated by pancreatitis; and group 3 (n = 33), ERCP with perforation.

RESULTS

Of 33 patients with confirmed ERCP-related perforations, only seven patients required surgical intervention. The overall length of hospital stay (6.5 +/- 3.5 days) was significantly longer (P = 0.003) than that of a random group of patients with the complication of post-ERCP pancreatitis (4.7 +/- 2.6 days). According to univariate analysis, risk factors included: sphincterotomy (odds ratio [OR] 9.0, 95 % confidence interval [CI] 3.2 - 28.1); sphincter of Oddi dysfunction (OR 3.8, 95 % CI 1.4 - 11.0); and dilated common bile duct (OR 4.07, 95 % CI 1.63 - 10.18, P = 0.003). In the multivariate logistic regression analysis, additional predictive factors included the duration of procedure (OR 1.021, 95 % CI 1.006 - 1.036), and biliary stricture dilation (OR 7.2, 95 % CI 1.84 - 28.11).

CONCLUSIONS

(i) The incidence of ERCP-related perforations is very low (0.35 %). (ii) Esophageal, gastric and duodenal perforations usually require surgery, but sphincterotomy- and guide wire-related perforations rarely do so. (iii) Factors which carry increased risk of an ERCP-related perforation include suspected sphincter of Oddi dysfunction, greater age, a dilated bile duct, sphincterotomy, and longer duration of the procedure.

Yield of colonoscopy in patients with nonacute rectal bleeding: a multicenter database study of 1766 patients

OBJECTIVE

There are few data to guide the choice between colonoscopy and flexible sigmoidoscopy in patients with nonacute rectal bleeding, especially in younger age groups. Our aim was to determine the yield of colonoscopy for significant proximal large bowel disease in the absence of significant distal disease, with special reference to young patients.

METHODS

This was a retrospective study of data collected prospectively in 1766 patients (median age 57 yr, 711 women). The endoscopic database (GI-Trac) contained 152 discrete fields for data input. Multiple logistic regression analysis was performed to identify variables independently associated with the presence of isolated significant proximal disease.

RESULTS

Young patients had a higher percentage of normal examinations than did older patients. The incidence of diverticular disease, small polyps, large polyps, and cancer rose with increasing age. No patient aged <40 yr had an isolated proximal cancer, but 7% had other significant isolated proximal disease. There was no overall association between age and significant proximal disease in the absence of significant distal disease (p = 0.66). The only variable associated with isolated proximal disease was anemia (odds ratio = 1.81; 95% CI = 1.11-2.93; p = 0.02).

CONCLUSION

The yield of colonoscopy (beyond the range of sigmoidoscopy) for neoplasia is low in patients aged <40 yr, but other significant disease may be missed if age is the only criterion determining colonoscopy use.

The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single-center experience

BACKGROUND

The aims of this study were to determine the utility of EUS and EUS-guided fine needle aspiration (EUS-FNA) in the detection and confirmation of celiac lymph node metastasis in patients with esophageal cancer and to define EUS features predictive of celiac lymph node metastasis in these patients.

METHODS

The records of 211 patients with esophageal cancer who underwent EUS staging were reviewed. The operating characteristics of EUS were determined in patients where either surgery, EUS-FNA of a celiac lymph node, or both were performed (n = 102). The association between selected variables and the presence of celiac lymph node metastasis was evaluated by univariate and multivariable analyses.

RESULTS

EUS in 48 patients provided a true-positive diagnosis of celiac lymph node involvement, a false-positive and false-negative result, respectively, in 6 and 14 patients, and a true-negative diagnosis in 34 patients. The sensitivity of EUS in detecting celiac lymph node was 77% (95% CI [67, 88]), specificity 85% (95% CI [74, 96]), negative predictive value 71% (95% CI [58, 84]), and the positive predictive value 89% (95% CI [81, 97]). EUS-FNA was performed in 94% (51/54) of patients with celiac lymph nodes. The accuracy of EUS-FNA in detecting malignant celiac lymph nodes was 98% (95% CI [90, 100]). Advanced T-stage, the need for dilation, detection of peritumoral lymph nodes, and black race were associated with celiac lymph node involvement. In multivariable analysis, advanced T-stage was the strongest predictor of celiac lymph node involvement.

CONCLUSION

EUS and EUS-FNA are highly accurate in detecting and confirming celiac lymph nodes metastasis. Depth of tumor invasion as assessed by EUS is a strong predictor of celiac lymph node metastasis in patients with esophageal cancer.

Randomized controlled trial of EUS-guided fine needle aspiration techniques for the detection of malignant lymphadenopathy

BACKGROUND

EUS-guided fine needle aspiration (EUS-FNA) is a highly accurate method of detecting malignant lymphadenopathy. The optimal methods for performing EUS-FNA to maximize sensitivity and to minimize the number of needle passes necessary are unknown. This is a report of the results of a prospective randomized controlled trial to determine the effect of suction, the site of FNA (edge or center of lymph node), and the method of preparation of cytologic specimens on accuracy, number of needle passes needed, and specimen quality.

METHODS

Consecutive patients with lymphadenopathy detected by EUS underwent FNA. Each lymph node was sampled with or without suction and from the edge or center in a 2 x 2 factorial design. The samples were expressed onto slides for cytology, and the residual material in the needle was analyzed by the cytospin-cellblock technique. Each aspirate was individually characterized for a diagnosis of malignancy, cellularity, and bloodiness.

RESULTS

Forty-three patients with a total of 46 lymph nodes were evaluated. The final lymph node diagnosis was benign in 22 (48%), "suspicious for malignancy" in 6 (13%), and malignant in 18 (39%). The use of suction was associated with an increase in the cellularity of the specimen, but did not improve the likelihood of obtaining a correct diagnosis (OR 1.52: 95% CI [0.81, 2.85]). Samples obtained with suction were of worse quality because of excessive bloodiness (OR 4.7: 95% CI [1.99, 11.24]). Aspiration from the edge of the lymph node (compared with the center) did not increase the likelihood of a correct diagnosis (OR 1.16: 95% CI [0.42, 3.21]). For 78% of malignant lymph nodes, the correct diagnosis was obtained on the first needle pass and for 100% by the third pass. Cytospin-cellblock methods did not add any additional diagnostic information compared with direct smear cytology.

CONCLUSIONS

The traditional method of applying suction during EUS-FNA does not improve diagnostic accuracy and worsens specimen bloodiness compared with FNA without suction. The site of FNA within the lymph node does not affect accuracy. When EUS-FNA is necessary, our recommendation is up to 3 FNAs without suction from the most convenient and safe location within abnormal-appearing lymph nodes.

Clinical and demographic predictors of Barrett's esophagus among patients with gastroesophageal reflux disease: a multivariable analysis in veterans

BACKGROUND

The subgroup of patients with gastroesophageal reflux disease (GERD) that should undergo endoscopy to rule out Barrett's esophagus (BE) has not been well defined.

GOALS

To examine demographic and clinical variables predictive of BE before endoscopy.

STUDY

A validated GERD questionnaire was administered to 107 patients with biopsy-proven BE and to 104 patients with GERD but no BE shown by endoscopy. Frequent symptoms were defined as symptoms that occurred at least once or more each week. Severity of symptoms was rated on a scale from 1 to 4 (mild to very severe). Univariate analysis and multivariable logistic regression were performed to determine whether demographic characteristics and the duration, severity, and frequency of GERD symptoms were associated with the identification of BE.

RESULTS

Eighty-five percent of the GERD patients and 82% of the BE patients completed the questionnaire. There was no difference between the groups in terms of race, gender, or proton pump inhibitor use. The BE patients were older (median age, 64 vs. 57 years, p = 0.04). In multivariable logistic regression, an age of more than 40 years ( p = 0.008), the presence of heartburn or acid regurgitation ( p = 0.03), and heartburn more than once a week ( p = 0.007) were all independent predictors of the presence of BE. Interestingly, patients with BE were less likely to report severe GERD symptoms ( p = 0.0008) and nocturnal symptoms ( p = 0.03). Duration of symptoms, race, alcohol, and smoking history were not associated with BE.

CONCLUSIONS

Upper endoscopy should be performed in GERD patients more than 40 years of age who report heartburn once or more per week. The severity of symptoms and the presence of nocturnal symptoms are not reliable indicators of the presence of BE.

Predictors of survival for esophageal cancer patients with and without celiac axis lymphadenopathy: impact of staging endosonography

BACKGROUND

Esophageal cancer patients with M1a disease are reported to have poor survival. We hypothesized that patients with celiac lymph node metastases (CLN) identified by endoscopic ultrasonography (EUS) would predict a cohort with significantly worse survival postoperatively. Accurate preoperative identification of this group will facilitate future adjuvant studies.

METHODS

During the study period, 211 patients with esophageal cancer underwent EUS staging. Patients with evaluable celiac axis (n = 182) were included in this study. Survival of patients with and without CLNs was compared and the factors affecting overall survival were assessed. A subgroup analysis based on CLN status was performed in the subgroup of patients who underwent surgical procedures.

RESULTS

Follow-up data was available in 91.2% (166 of 182) of the patients. As staged by EUS, T1, T2, T3, and T4 tumors accounted for 9.3%, 11.5%, 56%, and 21% of the cases, respectively. At least one CLN was imaged by EUS in 40% (72 of 182). The 5-year survival in patients with CLNs detected by EUS was 13% (95% confidence interval, 5% to 21%) compared with 30% (95% confidence interval, 21% to 40%) in patients with no CLNs detected by EUS (p = 0.007). In the subgroup of patients who underwent surgical procedures (n = 68), patients with CLN involvement had worse survival compared with those who did not have malignant involvement of CLNs at the time of their operation (median survival 39.8 versus 13.8 months, p = 0.0008). In a Cox proportional model, adjusting for race and the type of therapy, patients with CLN involvement or advanced EUS American Joint Committee on Cancer stage were more likely to have worse survival (p < 0.05)

CONCLUSIONS

EUS base line findings correlate with long term survival in patients with esophageal cancer. Patients with M1a disease as identified by EUS had a significantly worse postoperative survival when compared with non-M1a patients. This cohort of patients will be ideal for the study of induction therapy since the effect of down staging can be assessed before operation.

Immunogenicity of hepatitis A vaccination in decompensated cirrhotic patients

Hepatitis A virus (HAV) vaccination is recommended in chronic liver disease because of an increased morbidity and mortality associated with HAV superinfection. However, data regarding the efficacy of HAV vaccination in patients with advanced chronic liver disease is limited. We assessed the efficacy of a standard HAV vaccination schedule in decompensated chronic liver disease in comparison with compensated disease and defined clinical predictors associated with seroconversion. Eighty-four anti-HAV antibody-negative patients, 49 with compensated liver disease, and 35 with decompensated disease were enrolled. Seroconversion was measured by qualitative and quantitative anti-HAV antibody measurements 1 month after each vaccine dose, and univariate/multivariate analysis was performed to define clinical predictors associated with seroconversion. One month after the primary dose, 71.4% of patients with compensated liver disease had detectable anti-HAV antibody compared with 37.1% with decompensated liver disease (P <.05). One month after the booster dose, 98% of compensated patients seroconverted compared with 65.7% with decompensated disease (P <.05). The median serum antibody concentration in compensated liver disease was 76.4 mIU/mL at month 1 and 327.91 mIU/mL at month 7 compared with 20.0 mIU/mL and 102.57 mIU/mL, respectively, in decompensated disease. On multivariate analysis, Child-Pugh class was the only factor predicting response to vaccination. Seroconversion after HAV vaccination was significantly less common in decompensated liver disease and the presence of advanced disease (Child-Pugh class B/C) predicted a lower response rate. These findings indicate that the response to HAV vaccination in chronic liver disease is optimal when targeted to patients before the development of hepatic decompensation.

Factors associated with acceptance and full publication of GI endoscopic research originally published in abstract form

BACKGROUND

Many abstracts submitted to annual scientific meetings never come to full publication in peer-reviewed journals. The objective of this study was to determine factors associated with the fate of endoscopic research abstracts submitted to the annual scientific meeting of the American Society for Gastrointestinal Endoscopy (ASGE).

METHODS

All abstracts (n = 461) submitted to the annual meeting of the ASGE in May of 1994 were retrospectively reviewed. The following databases were searched for evidence of publication of abstracts in full-manuscript form: Medline, HealthSTAR, Current Contents, CINHAL, and Cancerlit. All abstracts were reviewed between May 4, 1998 and June 30, 1998. Univariate and multivariate analysis were performed to determine the association between abstract characteristics and acceptance for presentation at the meeting and for publication.

RESULTS

Fifty-five percent (247/451) of submitted abstracts were accepted for presentation. In univariate analysis, pediatric studies, prospective studies, randomized studies, and studies from university-affiliated medical centers (UAMC), were more likely to be accepted for presentation (p < 0.05). In multivariate analysis, the variables: pediatric studies (p = 0.01), prospective studies (p = 0.005), randomized studies (p = 0.06), and studies from UAMC (p = 0.01) predicted acceptance of abstracts for presentation at the meeting. The overall publication rate was 25.1%. The publication rates 1, 2, 3, and 4 years after the meeting were 6.7%, 16.2%, 22.8%, and 25.1%, respectively. Multivariate Cox proportional hazards analysis showed that accepted abstracts (p = 0.0003) studies reporting positive results (p = 0.0015), and studies from outside the United States (p = 0.036) were more likely to be published in manuscript form.

CONCLUSIONS

The overall publication rate of abstracts reporting endoscopic research is 25%, lower than that in any published report from other medical societies. Abstracts from the United States were less likely to be published in full-manuscript form. Although there was no positive outcome bias for acceptance of abstracts for presentation at the meeting, there was bias toward publication of statistically significant results. Further investigations are warranted to determine the variation in the publication of research results according to country of origin and to determine factors that hinder publication of GI endoscopic research in manuscript form.

Barrett's oesophagus: a review of costs of the illness

Barrett's oesophagus is a premalignant complication that occurs in approximately 10% of patients with gastro-oesophageal reflux disease (GORD). In patients with Barrett's oesophagus, the risk of adenocarcinoma of the oesophagus approaches 0.5% per patient-years. Therefore, practice guidelines have been developed that suggest screening patients with GORD, particularly those with long-standing symptoms and those aged > or =50 years for the presence of Barrett's metaplasia. These guidelines also suggest performing surveillance endoscopy for the development of dysplasia and/or cancer in patients found to harbour Barrett's oesophagus at initial screening with the frequency of subsequent endoscopies dictated by the presence and grade of dysplasia. In patients with high-grade dysplasia and/or early adenocarcinoma, oesophagectomy is curative. Given the important clinical and economic implications of GORD complicated by Barrett's oesophagus, we review the costs associated with screening, surveillance and treatment for this condition. Although the majority of physicians recommend and/or perform surveillance for dysplasia in the setting of Barrett's oesophagus, differences in endoscopic technique, surveillance intervals and cancer perception among practitioners influence total costs. In the US, it is estimated that a population-wide surveillance program could potentially result in a total cost of 289.9 million US dollars. The outpatient management of Barrett's oesophagus is estimated to cost 1241 US dollars per year with medication use alone accounting for over half of the total costs. Cost-effectiveness analyses have been performed to evaluate the economic impact and benefit of surveillance for dysplasia and/or cancer. Studies to date have utilised several outcome measures such as life-years gained, quality-adjusted life-years and cases of cancer detected. Therefore, the incremental cost-effectiveness ratios reported have varied greatly and are particularly sensitive to the prevalence of Barrett's oesophagus in patients with GORD and the incidence of adenocarcinoma. Further epidemiological and clinical studies are likely to further define the economic impact of Barrett's oesophagus as a complication of GORD.

Mucinous tumors of the exocrine pancreas

BACKGROUND

Mucin-producing cystic neoplasms of the pancreas account for 1% of all malignant tumors of the pancreas. They include mucinous cystic neoplasms (MCNs) and mucinous ductal ectasia (MDE), also known as intraductal mucin-hypersecreting neoplasms.

METHODS

This review focuses on the clinical presentation, the role of diagnostic imaging modalities, and cyst fluid analysis preoperatively in the differentiation between these tumors and other nonneoplastic cysts of the pancreas.

RESULTS

MCNs and MDE evolve from pancreatic duct epithelium, produce an abundance of mucin, and are considered premalignant or malignant. While MCNs affect primarily middle-aged women with lesions occurring predominantly in the body and tail of the pancreas, MDE affects primarily men in the sixth or seventh decade with lesions more often located in the head of the pancreas.

CONCLUSIONS

All mucin-producing cystic tumors of both types require surgical resection because they are frankly malignant or premalignant. Survival rates of both tumors are better than those reported for ductal cell carcinomas. Future studies are needed to improve the accuracy of diagnosing these tumors preoperatively.

Health-related quality of life and severity of symptoms in patients with Barrett's esophagus and gastroesophageal reflux disease patients without Barrett's esophagus

OBJECTIVES

The aims of this study were: 1) to compare the health-related quality of life (HRQL) of patients with Barrett's esophagus (BE) to that of patients with GERD who did not have BE; 2) to compare HRQL of gastroesophageal reflux disease (GERD) patients to that of normative data for the US general population; and 3) to examine the impact of GERD symptom frequency and severity on HRQL.

METHODS

The SF-36 and a validated GERD questionnaire were administered to 107 patients with biopsy-proven BE and to 104 patients with GERD but no BE by endoscopy. Frequent symptoms were defined as symptoms that occurred at least once weekly. Severity of symptoms was rated on a scale from 1 to 4 (mild to very severe).

RESULTS

In all, 85% of the GERD patients and 82% of BE patients completed the questionnaires. There was no difference in the scores of the eight subscales of the SF-36 between BE patients and those with GERD but without BE (p > 0.05). However, both groups scored below average on all subscales of the SF-36 compared to published US norms for an age- and gender-matched group. Using multivariable linear regression, the social functioning subscale of the SF-36 correlated with the presence of heartburn or acid regurgitation, severity of acid regurgitation, frequency of heartburn, frequency of acid regurgitation, and number of comorbidities. Similarly, the physical functioning subscale correlated with age, frequency of heartburn, and number of comorbidities. The bodily pain subscale correlated with the frequency of heartburn and number of comorbidities. The bodily pain subscale correlated with the frequency of heartburn and the severity of dysphagia, whereas the role emotional subscale correlated with the frequency of heartburn and the presence of dysphagia.

CONCLUSIONS

Although there were no differences in HRQL between BE and GERD patients, both groups scored below average on the subscales of the SF-36 compared to normal controls. GERD symptom frequency and severity were associated with bodily pain and with impaired social, emotional, and physical functioning, suggesting a profound impact on daily living.

A cost analysis of outpatient care for patients with Barrett's esophagus in a managed care setting

OBJECTIVES

Although Barrett's esophagus (BE) may be associated with severe gastroesophageal reflux disease (GERD), there are currently no studies that evaluate resource utilization in Barrett's patients. The aims of this study were 1) to determine the cost and number of endoscopies and clinic visits to the GI clinic for GERD or its complications in patients with BE; 2) to determine the pattern and cost of medication use in patients with BE; and 3) to compare medication use by patients with BE to that of patients with insulin-requiring diabetes mellitus (DM).

METHODS

Using the cost distribution report data and the pharmacy acquisition costs from the Durham VAMC, we calculated the monthly cost of endoscopies, clinic visits related to GERD, and medication use in 53 patients with BE between 1/1/94 and 1/1/97. We also calculated the average cost of medication use for 55 patients with insulin-requiring DM.

RESULTS

All patients with BE were male. Their median age was 64.0 yr (IQR 57-68). Of them, 92% were white; 23% had low-grade dysplasia (LGD). Patients with LGD were more likely to have more than three endoscopies in 3 yr than were those with no LGD (OR 6.3, 95% CI 1.11-35.67). There was no difference in clinic visits in the patients with and without dysplasia (OR 0.335, 95% CI 0.093-1.206). A total of 139 endoscopies and 172 clinic visits were observed. Outpatient care for patients with BE costs approximately $103/month or $1241/yr. Endoscopies and clinic visits accounted for 31.1% and 5.9% of the monthly medical cost, respectively. Medications accounted for 63% of the total cost of care. Prokinetic agents accounted for 0.8% of the total cost of medications, whereas histamine receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs) accounted for 34.6% and 64.6%, respectively. Medication cost per month in patients with BE was approximately $65, similar to that of patients with insulin-requiring DM ($63).

CONCLUSIONS

Our conclusions were as follows: 1) Outpatient care for patients with BE costs approximately $1241/yr or ($103/month). 2) Medication use per month accounted for more than half of the total cost; PPIs accounted for 64.6% of total medication cost, suggesting that reflux was severe. 3) Consistent with current surveillance strategies, patients with LGD had more frequent endoscopy than patients with no dysplasia. 4) Medication cost per month in patients with BE is similar to that in patients with DM, another group with a chronic disorder. 5) Those who make health policy can use these results to compare the cost of care of patients with BE to the cost for those with other chronic medical disorders.

Does this patient have Barrett's esophagus? The utility of predicting Barrett's esophagus at the index endoscopy

OBJECTIVES

Few studies have evaluated the ability of the endoscopist to predict the presence of Barrett's esophagus (BE) at index endoscopy. The goals of this study were to determine the operating characteristics of endoscopy in diagnosing BE, and to determine the clinical and endoscopic predictors of BE in suspected BE patients at the index endoscopy.

METHODS

From September 1993 to October 1997, endoscopic reports were examined to identify patients with suspected BE. All esophageal pathology reports during the same period were evaluated for the presence of specialized intestinal metaplasia.

RESULTS

During the study period, 4053 endoscopies were performed on 2393 patients. Eight percent of all procedures were performed for suspected or confirmed BE. Fifty-three patients were known to have BE and thus their reports were excluded from this analysis. Five hundred seventy of the remaining patients had esophageal biopsies performed, and were included in this analysis. Among these 570 patients, 146 were suspected to have BE on endoscopy, while 424 were not suspected to have BE at the time of endoscopy. There were no differences among the two groups in terms of gender, race, and dyspepsia as an indication for the endoscopy. However, suspected BE patients were slightly younger and were more likely to have heartburn, but were less likely to have dysphagia as an indication for the endoscopy. The sensitivity and specificity of the endoscopists' assessments were 82% (95% confidence interval [CI], 72-92) and 81% (95% CI, 78-84), respectively. The positive predictive value and the negative predictive value were 34% and 97%, respectively. The positive likelihood ratio was 4.32 (95% CI, 3.49-5.31) and the negative likelihood ratio was 0.22 (95% CI, 0.13-0.38). Univariate analysis showed that endoscopists diagnosed BE in those with long-segment BE (LSBE) more accurately than in those with short-segment BE (SSBE) (55% vs 25% p = 0.001; odds ratio [OR] = 3.63, 95% CI, 1.71-7.70). Barrett's esophagus was correctly diagnosed in 38.5% of white patients but in only 14.7% of black patients (p = 0.01; OR = 3.63, 95% CI, 1.31-10.13). Multivariable logistic regression identified only the length of the columnar-appearing segment (p = 0.002; OR = 3.33, 95% CI, 1.54-7.17) and race (p = 0.08; OR = 2.31, 95% CI, 0.88-6.03) to be associated with the presence of BE on biopsy.

CONCLUSIONS

Barrett's esophagus is frequently suspected at endoscopy; SSBE was more frequently suspected than LSBE, but was correctly diagnosed only 25% of the time, versus 55% for LSBE. Endoscopists diagnosed BE with a sensitivity of 82% and a specificity of 81%. However, the positive predictive value was only 34%, whereas the negative predictive value was 97%. The length of the columnar-appearing segment is the strongest predictor of BE at endoscopy. Alternative methods are needed to better identify BE patients endoscopically, especially those with SSBE.

The great imitator: Rocky Mountain spotted fever occurring after hospitalization for unrelated illnesses

We describe two patients who had Rocky Mountain spotted fever after they were admitted to the hospital for emergency and elective surgical procedures. We initially thought one patient had a hospital-acquired infection; the correct diagnosis was deduced from epidemiologic clues elicited by consultants. These two cases were also unusual in that one patient had a recurrent rash after an abbreviated course of low-dose doxycycline therapy and the other patient had transient and self-limiting postinfectious polyneuropathy. These cases illustrate that community-acquired infection with Rickettsia rickettsii can occur simultaneously with other disease processes and sometimes mimic a nosocomial infection.

Predictors of prognosis and risk of acute renal failure in patients with Rocky Mountain spotted fever

BACKGROUND

Acute renal failure has long been associated with severe Rocky Mountain spotted fever (RMSF). Despite many descriptions of the protean manifestations of this disease, relatively little is known concerning the risk factors for acute renal failure. Only a few studies have examined the outcome of patients infected with Rickettsia rickettsii who develop renal insufficiency, and these studies had methodological problems.

OBJECTIVE

To study the incidence, risk factors, and outcomes of acute renal failure in a large group of hospitalized patients with definite or probable RMSF.

METHODS

The clinical records of 114 patients with definite or probable RMSF were retrospectively reviewed to identify clinical and biochemical abnormalities at the time of admission that were associated with the development of acute renal failure and subsequent mortality. Renal failure was defined as a serum creatinine (Cr) above 2 mg/dL. Logistic regression was used to study the association between these variables and the outcomes during hospitalization: death and the development of acute renal failure.

RESULTS

The mortality rate in this series was 14%; 19% of the patients developed acute renal failure. The development of acute renal failure increased the odds ratio (OR) of dying by a factor of 17 (P = 0.001). Factors at the time of hospitalization that were associated at a univariate level with subsequent mortality included elevated serum Cr, increased age, increased level of AST, increased level of bilirubin, decreased serum sodium and platelet count, the presence of neurological involvement, and being male. Both the presence of neurological involvement and an elevated serum Cr at presentation were independently associated with increased mortality by multivariate analysis. Three patients developed acute renal failure that required hemodialysis, and only 1 of these 3 patients survived; he was ultimately discharged with a normal serum Cr. Factors at presentation that were associated with the development of acute renal failure included increased bilirubin, increasing age, thrombocytopenia, and the presence of neurological involvement. Both age and decreased platelet count at presentation were independently associated with the development of acute renal failure by multivariate analysis.

CONCLUSION

Acute renal failure was a frequent complication of RMSF in this series of patients from a tertiary referral medical center. The presence of acute renal failure was strongly associated with death. Clinical and biochemical variables are useful in predicting which patients will develop acute renal failure.