Mallory-Weiss tear: predisposing factors and predictors of a complicated course

OBJECTIVES

Little has been published regarding predictors of a complicated course after Mallory-Weiss tear (MWT). The aims of this study were to identify risk factors for a Mallory-Weiss tear and factors predictive of a complicated course.

METHODS

At our university hospital, we searched a computerized endoscopy database. At our Veterans Affairs hospital we manually searched printed endoscopy reports. Proposed risk factors for MWT were: history of alcohol use, recent alcohol binge, nonbloody initial emesis, anticoagulation, other coagulopathy, nonsteroidal anti-inflammatory use, and hiatal hernia. Proposed predictors of a complicated course were: age, hematemesis, melena, hematochezia, visible vessel, adherent clot, active bleeding, multiple tears, other pathology at endoscopy, admission Hct, hypotension or orthostatic changes, and coagulopathy. A complicated course was defined on the basis of >6 U of blood transfused, rebleeding, angiography, surgery, or death. Predictors of a complicated course were evaluated using the Mann-Whitney U test or Fisher exact test.

RESULTS

A total of 73 cases were reviewed. The most common risk factor was alcohol use, which was found in 44% of cases. In all, 23% of patients had no risk factors. Of the patients, 17 (23%) had a complicated course. Patients with a complicated course had a lower admission Hct (p = 0.009) and active bleeding at initial endoscopy (p = 0.013).

CONCLUSION

The predictive value of active bleeding supports early endoscopy for stratification and intervention.

Age and alarm symptoms do not predict endoscopic findings among patients with dyspepsia: a multicentre database study

INTRODUCTION

Symptoms of dyspepsia are common but most patients do not have major upper gastrointestinal pathology. Endoscopy is recommended for dyspeptic patients over the age of 45, or those with certain "alarm" symptoms. We have evaluated the effectiveness of age and "alarm" symptoms for predicting major endoscopic findings in six practising endoscopy centres.

METHODS

Clinical variables of consecutive patients with dyspepsia symptoms undergoing upper endoscopy examinations were recorded using a common endoscopy database. Patients who had no previous upper endoscopy or barium radiography were included. Stepwise multivariate logistic regression was used to identify predictors of endoscopic findings. The accuracy of these for predicting endoscopic findings was evaluated with receiver operating characteristic analysis. The sensitivity and specificity of age thresholds from 30 to 70 years were evaluated.

RESULTS

Major pathology (tumour, ulcer, or stricture) was found at endoscopy in 787/3815 (21%) patients with dyspepsia. Age, male sex, bleeding, and anaemia were found to be significant but weak independent predictors of endoscopic findings. A multivariate prediction rule based on these factors had poor predictive accuracy (c statistic=0.62). Using a simplified prediction rule of age > or =45 years or the presence of any "alarm" symptom, sensitivity was 87% and specificity was 26%. Increasing or decreasing the age cut off did not significantly improve the predictive accuracy.

CONCLUSIONS

Age and the presence of "alarm" symptoms are not effective predictors of endoscopic findings among patients with dyspepsia. Better clinical prediction strategies are needed to identify patients with significant upper gastrointestinal pathology.

Nonoperative management of bile leaks following liver transplantation

The biliary anastomosis has been called 'the Achilles heel' of liver transplantation (RABKIN JM, ORLOFF SL, REED MH. Transplantation 1998: 65 [2]: 193; DAVIDSON BR, RAI R, KURZAWINSKI TR. Br J Surg 1999: 86 [4]: 447). Biliary complications after liver transplantation reportedly occur at an incidence of 20-30%, 10-15% as bile leaks. The management of bile leaks, especially early bile leaks, is controversial. In the present study, we report our experience with the management of bile leaks after liver transplantation. In this retrospective study, we reviewed 85 liver transplants over a 3-yr period. In 79, the biliary anastomosis was choledochocholedochostomy (CDCD) over a small-caliber T-tube, while choledochojejunostomy (CDJ) was used in 7. Over a mean follow up period of 13.5 months (median 10 months), 10 patients (12%) experienced a clinically significant bile leak within the first 3 months after liver transplantation. The early leaks, occurring within 1 month of transplant, were successfully managed by observation (DAVIDSON BR, RAI R, KURZAWINSKI TR. Br J Surg 1999: 86 [4]: 447) or endoscopic retrograde cholangiopancreatography (ERCP) and the placement of a biliary stent for a duration of 6-12 wk (RANDALL HB, WACHS ME, SOMBERG KA. Transplantation 1996: 61 [2]: 258). One of these resulted from accidental dislodgement of the T-tube on postoperative day 1; one resulted from necrosis at the CDCD anastomosis and required CDJ; the remaining four resulted from leaks along the T-tube track. One of the late leaks occurred following the planned removal of the T-tube at 3 months after liver transplantation; the other two were leaks along the T-tube track. All were successfully treated by ERCP and stent placement, though in one case, ERCP was initially unsuccessful because of the inability to advance a guidewire, necessitating a fluoroscopically aided guide wire placement during a mini laparotomy. ERCP was then successfully performed with the placement of a stent. [See table in text]

CONCLUSIONS

Our experience indicates that most bile leaks after liver transplantation, including early leaks, can be successfully managed nonoperatively. Most will require intervention, but ERCP and stent placement are usually sufficient.

Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts

OBJECTIVE

To provide current information on the risks of endoscopic sphincterotomy for stone.

SUMMARY BACKGROUND DATA

In recent years (since the popularity of laparoscopic cholecystectomy), endoscopic sphincterotomy has been used increasingly for the management of bile duct stones in relatively young and healthy patients. The validity of this trend has been questioned using data on short-term complications derived from earlier decades that involved more elderly and high-risk patients.

METHODS

Seven academic centers collected data prospectively using a common database. Complications within 30 days of the procedures were documented by standard criteria.

RESULTS

Of 1921 patients, 112 (5.8%) developed complications; two thirds of these events were graded as mild (<3 days in hospital). There was no evidence of increased risk in younger patients or in those with smaller bile ducts. There was only one severe complication and there were no fatalities in 238 patients age <60, with bile duct diameters of <9 mm.

CONCLUSION

Sphincterotomy for stones can be performed very safely by experienced endoscopists.

Patterns of esophageal motility in patients with stable bulimia

OBJECTIVES

A high prevalence of GI motility disturbances, including deranged esophageal motility, has previously been reported in patients with eating disorders; altered esophageal and gastric motility have been suggested to play an important role in these disease processes. We sought to confirm this association in an independent patient population.

METHODS

We performed esophageal manometry in 12 patients with eating disorders (eight patients with bulimia and four with overlap syndromes, including both anorexia and bulimia features) and 12 sex-matched controls. All subjects completed a symptom questionnaire. Motility testing was performed in the standard fashion using a low compliance water perfusion catheter and computerized digital data capture. Coded tracings were interpreted in a blinded fashion.

RESULTS

All 24 studies showed normal motility patterns [95% confidence interval for abnormal esophageal motility in eating disorders patients (0, 0.27)]. Mean lower esophageal sphincter pressure was 24.4 mm Hg in patients and 21.8 in controls; all relaxed normally. Mean esophageal body contraction amplitude 3 cm above the lower esophageal sphincter was 82.6 mm Hg in patients and 84.3 in controls; waveform morphology and progression met normal criteria in all studies. Eight of 12 patients reported dysphagia, odynophagia, or both, compared with 1 of 12 controls; patients demonstrated a pattern of increased overall GI symptomatology compared to controls.

CONCLUSIONS

We conclude that disordered esophageal motility is uncommon among stable eating disorder outpatients with bulimic features, and that dysphagia and odynophagia are rarely associated with disordered motility in this group.

Clinical implications of endoscopic ultrasound: the American Endosonography Club Study

BACKGROUND

Despite increased clinical use of endoscopic ultrasound (EUS), there are little data regarding complications of EUS or its impact on patient management.

METHODS

A prospective multicenter study was completed to evaluate clinical outcomes of EUS. Before each EUS examination the endosonographer recorded further theoretical patient management plans as if EUS was unavailable. After the EUS, endosonographers recorded actual management plans based on EUS results. The actual management plan after EUS was compared to the theoretical management before EUS. Complications were assessed in short-term follow-up.

RESULTS

Four hundred twenty-eight subjects were enrolled. Of subjects able to be evaluated, EUS changed the treatment plan in 74%. Management changes of major importance occurred in 120 patients (31% of subjects able to be evaluated) and included decisions regarding surgery (62 patients), decisions regarding nonsurgical invasive management (36 patients), and decisions regarding further follow-up (22 patients). When there was a change in management, the change was to less costly, risky, or invasive management in 55%, to more costly/risky/invasive in 37%, and to equally costly/risky/invasive in 8%. Short-term follow-up was completed in 81% of subjects, with six complications identified (1.7%). Three complications were mild, two were moderate, one severe, and none fatal.

CONCLUSIONS

(1) Changes in management plan may occur in the majority of patients based on EUS results. (2) The management changes are often of major importance with regard to health care costs and safety, and are more often in the direction of less costly, risky, and invasive management. (3) EUS is safe in experienced hands.

Gastrointestinal and nutritional aspects of eating disorders

Anorexia nervosa (AN) and bulimia nervosa (BN) are potentially fatal eating disorders which primarily affect adolescent females. Differentiating eating disorders from primary gastrointestinal (GI) disease may be difficult. GI disorders are common in eating disorder patients, symptomatic complaints being seen in over half. Moreover, many GI diseases sometimes resemble eating disorders. Inflammatory bowel disease, acid peptic diseases, and intestinal motility disorders such as achalasia may mimic eating disorders. However, it is usually possible to distinguish these by applying the diagnostic criteria for eating disorders and by obtaining common biochemical tests. The primary features of AN are profound weight loss due to self starvation and body image distortion; BN is characterized by binge eating and self purging of ingested food by vomiting or laxative abuse. GI complications in eating disorders are common. Recurrent emesis in BN is associated with dental abnormalities, parotid enlargement, and electrolyte disturbances including metabolic alkalosis. Hyperamylasemia of salivary origin is regularly seen, but may lead do an erroneous diagnosis of pancreatitis. Despite the weight loss often seen in eating disorders, serum albumin, cholesterol, and carotene are usually normal. However, serum levels of trace metals such as zinc and copper often are depressed, and hypophosphatemia can occur during refeeding. Patients with eating disorders frequently have gastric emptying abnormalities, causing bloating, postprandial fullness, and vomiting. This usually improves with refeeding, but sometimes treatment with pro-motility agents such as metoclopromide is necessary. Knowledge of the GI manifestations of eating disorders, and a high index of suspicion for one condition masquerading as the other, are required for the correct diagnosis and management of these patients.

Noninvasive detection of Helicobacter pylori colonization in stomach using [11C]urea

Helicobacter pylori is associated with chronic type B gastritis. Diagnosis can be made on gastric biopsy specimens and noninvasively using [13C]- or [14C]urea breath tests. Both breath tests require meticulous breath collection, and false positive results are possible from urease producing oral-pharyngeal flora. We used [11C]urea, a positron-emitting radionuclide allowing dynamic imaging, to measure metabolism of urea in the stomach of biopsy documented H. pylori-positive patients. [11C]urea was synthesized from 11CO2 produced using a Van de Graaff accelerator and administered with [99mTc]DTPA to control for loss of radioactivity via gastric emptying. Images were obtained externally by gamma camera every minute and 11CO2 was monitored in the breath continuously for 30 min. An H. pylori-positive patient exhibited a 99mTc/11C activity ratio of 2:1 in the stomach 10-20 min following administration, compared to a 1:1 ratio in a negative control, indicating metabolism of urea to 11CO2 with subsequent diffusion of 11C activity out of the stomach. The 11C activity in the breath peaked at 10-20 min in the H. pylori-positive patients. The short half-life of carbon-11 (20.4 min) alleviates radiation safety concerns and results in low absorbed radiation doses to patients.

Mucinous pancreatic tumors: ERCP findings

Mucin-producing tumors of the pancreas are rare and difficult to diagnose neoplasms. To further characterize the nature of these lesions, four such cases are described here in which the diagnosis was suspected at endoscopic retrograde cholangiopancreatography by the presence of ampullary or intraductal mucus. In one patient, pancreatoscopy directly visualized the tumor. Ultrasound and computed tomography failed to suggest the presence of a neoplasm in the majority of these cases, but endoscopic ultrasound was performed in one and correctly identified the multi-cystic tumor. A high incidence of acute pancreatitis was seen in these cases and was felt to be secondary to intermittent ductal obstruction by mucus. The characteristic appearance of intra-ductal mucus provides an important clue to the presence of this type of pancreatic neoplasia.

Studies of gastric ulcer disease by community-based gastroenterologists

A community-based group of gastroenterologists examined 623 patients (541 prospectively and 82 retrospectively) with endoscopically diagnosed gastric ulcer disease during a 12-month period. Patients averaged 60 years of age; the majority were women (62%). Women were less likely to smoke, abuse alcohol, and were more likely to present with abdominal pain (p less than 0.05). Whereas patients presenting with bleeding or requiring transfusion were less likely to complain of pain (p less than 0.05), they were more likely to be taking aspirin or nonsteroidal anti-inflammatory drugs and have prior history of bleeding (p less than 0.05). Patients with a prior history of ulcer disease were more likely to smoke, present with pain and use acetaminophen (p less than 0.05). Patients with large ulcers were more likely to bleed, present with pain, and obstruct (p less than 0.05). Multiple gastric ulcers were seen in patients taking aspirin or nonsteroidal anti-inflammatory drugs (p less than 0.05).

Clinical application of endoscopic ultrasonography

During the course of routine clinical practice in 48 patients, 50 endoscopic ultrasound (EUS) examinations were performed over a 1-yr period, with all patient data collected prospectively. Organs examined were the esophagus, stomach, duodenum, ampulla, pancreas, common bile duct, and gallbladder. There were 18 staging exams of known neoplasms, and 24 examinations to evaluate possible mass. Forty-three examinations were successful, four failed due to instrument malfunction, and three were technical failures. Among 35 exams for masses, follow-up pathology was available in 21 and confirmed EUS findings in 90%. EUS yielded additional information, not available by other imaging studies, in 60% of successful exams. No complications were seen. The recent literature is reviewed in approximately 2000 patients. We conclude that EUS is an accurate and safe method for evaluating upper gastrointestinal pathology, particularly for staging neoplasms.