Quality control of colonoscopy procedures: a prospective validated method for the evaluation of professional practices applicable to all endoscopic units

OBJECTIVES

To produce valid information, an evaluation of professional practices has to assess the quality of all practices before, during and after the procedure under study. Several auditing techniques have been proposed for colonoscopy. The purpose of this work is to describe a straightforward original validated method for the prospective evaluation of professional practices in the field of colonoscopy applicable in all endoscopy units without increasing the staff work load.

METHODS

Pertinent quality-control criteria (14 items) were identified by the endoscopists at the Cochin Hospital and were compatible with: findings in the available literature; guidelines proposed by the Superior Health Authority; and application in any endoscopy unit. Prospective routine data were collected and the methodology validated by evaluating 50 colonoscopies every quarter for one year.

RESULTS

The relevance of the criteria was assessed using data collected during four separate periods. The standard checklist was complete for 57% of the colonoscopy procedures. The colonoscopy procedure was appropriate according to national guidelines in 94% of cases. These observations were particularly noteworthy: the quality of the colonic preparation was insufficient for 9% of the procedures; complete colonoscopy was achieved for 93% of patients; and 0.38 adenomas and 0.045 carcinomas were identified per colonoscopy.

CONCLUSION

This simple and reproducible method can be used for valid quality-control audits in all endoscopy units. In France, unit-wide application of this method enables endoscopists to validate 100 of the 250 points required for continuous medical training. This is a quality-control tool that can be applied annually, using a random month to evaluate any changes in routine practices.

[Surgical management of primary esophageal motility disorders]

Primary esophageal motility disorders are rare, the most common diagnoses being achalasia and diffuse esophageal spasm. Treatment aims to alleviate symptoms and may be medical, endoscopic, or surgical. Achalasia is most commonly treated by pneumatic dilatation or by laparoscopic Heller cardiomyotomy. Pneumatic dilatation is effective in 60-80% of cases, but functional results deteriorate over time. Surgical treatment is indicated when endoscopic dilatation is contraindicated or has failed. Functional results after cardiomyotomy are satisfactory in 90% of cases and results appear to be stable over time. The need for an associated antireflux procedure and the type of fundoplication remain controversial. For diffuse esophageal spasm, extended esophageal myotomy has yielded satisfactory functional results, but surgical treatment should be reserved for selected patients with severe symptoms.

Esophageal lichen planus: a series of eight cases including a patient with esophageal verrucous carcinoma. A case series

Esophageal lichen planus is a rare condition. Its risk of malignant transformation is unknown. We report a series of eight patients with esophageal lichen planus referred to our unit between 1990 and 2005. Clinical, endoscopic, radiological and histological data of these patients were retrospectively reviewed. Seven patients were women. All patients had oral lichen planus. Endoscopic lesions were located in the upper third of the esophagus in seven patients and in the mid third in two patients. Five patients had esophageal stricture. Seven patients had peeling, friable esophageal mucosa. Histological examination of esophageal biopsies found characteristic features of lichen planus in two patients and nonspecific changes in five patients. All patients received corticosteroids. Patients with stricture underwent esophageal dilation. Esophageal perforation after dilation occurred in one patient. Corticosteroids improved dysphagia in all patients; steroid dependence occurred in two patients with stricture. One patient had an esophageal verrucous carcinoma, which was treated with radiotherapy and chemotherapy. Upper endoscopy should be performed in patients with mucosal lichen planus presenting with dysphagia to assess esophageal involvement. Esophageal strictures are frequent and require dilation. Corticosteroids are the first-line treatment, but steroid dependence may occur. Cancer can arise on esophageal lichen planus and justifies endoscopic follow-up.

Capsule endoscopy and bowel preparation with oral sodium phosphate: a prospective randomized controlled trial

BACKGROUND

Capsule endoscopy (CE) is the first procedure to explore the small bowel in obscure GI bleeding (OGB).

OBJECTIVE

To evaluate the role of bowel preparation with oral sodium phosphate (NaP) in this indication.

DESIGN

A prospective multicenter, controlled, randomized, blind study.

METHODS

A total of 129 patients with the diagnosis of OGB were included and were randomized into 2 groups (group A [n = 64] and group B [n = 63]). In group A, a CE was performed after an 8-hour fasting period. In group B, patients were asked to drink 2 doses of 45 mL NaP before swallowing the capsule. The quality of the images was assessed at 5 different locations of the small bowel. Bowel cleanliness and visibility were evaluated by using 2 scoring systems, which included assessing the presence of bubbles, liquid, and the rate of visibility.

RESULTS

A total of 127 patients (53 men; mean age 56.9 years, range 19-90 years) were analyzed for the preparation and detection of lesions (2 patients were not able to swallow the capsule). No difference was observed for cleanliness and visibility between the 2 groups at any of the small-bowel segments; no difference was found for gastric transit time (39.8 minutes vs 35.7 minutes, P = .63), small-bowel transit time (257.5 minutes vs 248.6 minutes, P = .59), and the detection of lesions (35.9% vs 42.8%, P = .54).

LIMITATIONS

The evaluation of bowel cleanliness was based on subjective features.

CONCLUSIONS

The results of the present study, despite a significant number of limitations, did not support that small-bowel preparation with oral NaP can be recommended for CE exploration in patients with OGB.

Computed virtual chromoendoscopy system (FICE): a new tool for upper endoscopy?

OBJECTIVES

A newly developed computed virtual chromoendoscopy system, Fuji Intelligent Color Enhancement (FICE) technology, decomposes images by wavelength, then directly produces reconstructed images with enhanced mucosal surface contrast. The aims of the present study were to determine the quality of information provided by computed virtual chromoendoscopy for detecting gastrointestinal polyps and to identify the best channel setting for imaging.

PATIENTS AND METHODS

Thirty-one upper endoscopy procedures were performed in 31 patients using Fujinon 1.3-million-pixel endoscopes with zoom. A polyp was diagnosed in 45% of the patients. Six experienced endoscopists, who had never used the computed virtual chromoendoscopy system before, analysed the 31 endoscopy reports. Each endoscopy report included 11 images (one conventional image and one image for each FICE channel). The endoscopists used a 10-cm analog visual scale to determine the three best FICE channels, and to evaluate the quality and pit pattern of the chromoendoscopy images.

RESULTS

Channel 4 (red: 520; green: 500; blue: 405) was considered the best channel in 39.7% of the reports (p<0.0001) and was among the best three in 77%. For 94.1% of the reports, the best FICE channel image was considered superior to the conventional image (p<0.0001). Median pit pattern score was 9.43 for computed virtual chromoendoscopy and 7.08 for conventional endoscopy (p<0.001).

CONCLUSION

Fuji Intelligent Color Enhancement (FICE) channel 4 images were significantly better than conventional images. Computed virtual chromoendoscopy enabled better analysis of the pit pattern and the normal-pathological mucosal junction. Computed virtual chromoendoscopy can be used to identify gastroduodenal polyps and to assist in complete polypectomy.

Functional results after extended myotomy for diffuse oesophageal spasm

BACKGROUND

The role of surgery in the management of patients with diffuse oesophageal spasm (DOS) remains controversial. The aim of this study was to assess functional results after extended myotomy for DOS.

METHODS

This prospective study evaluated 20 patients who had extended myotomy (14 cm on the oesophagus and 2 cm below the oesophagogastric junction) with anterior fundoplication via a laparotomy for severe DOS. Median follow-up was 50 (range 6-84) months. Functional data were assessed by means of dysphagia (range 0-3), chest pain (range 0-3) and overall clinical (range 0-12, including dysphagia, chest pain, regurgitation, gastro-oesophageal reflux) scores.

RESULTS

All patients had severe DOS. The median preoperative overall clinical score was 6 (range 3-8) with a dysphagia score of at least 2. Median postoperative functional scores were significantly lower than preoperative values (overall clinical score 1 versus 6, dysphagia score 0 versus 3, chest pain score 0 versus 2). At final follow-up, good or excellent results were obtained for overall clinical score in 16 patients, for dysphagia score in 18 and for chest pain score in all 20 patients. Postoperative gastro-oesophageal reflux was noted in two of the 20 patients.

CONCLUSION

Extended myotomy with anterior fundoplication is an effective treatment for severe DOS. Medium-term postoperative functional results were excellent, especially in terms of dysphagia and chest pain.

Portal hypertensive duodenal polyp: A case report

Abnormalities of gastric mucosa in patients with portal hypertension are well documented. Manifestations of portal hypertension in small bowel and colon are less common. Colonic polypoid lesions microscopically consisting of a normal mucosa, with dilatation of submucosal vessels, have been described. We here report the first case of portal hypertensive duodenal polyp, responsible for gastro-intestinal bleeding. Endoscopic treatment turned out to be successful.

Functional results after laparoscopic Heller myotomy for achalasia: A comparative study to open surgery

BACKGROUND

Prospective studies comparing laparoscopic to open Heller myotomy for esophageal achalasia are lacking. The aim of this study was to compare functional outcome after laparoscopic and open Heller myotomy for esophageal achalasia.

METHODS

Eighty-two patients who underwent Heller-Dor myotomy for achalasia, via laparoscopy (n=52) or open surgery (n=30) were recorded prospectively (1993-2002). Median follow-up was 51 (12-111) months. Perioperative functional data were assessed via dysphagia and overall clinical (dysphagia, chest pain, regurgitation, gastroesophageal reflux) scores.

RESULTS

In laparoscopy patients, the operative time was longer (145 [95-290] vs 120 [70-230] minutes, P <.0001); the postoperative hospital stay and feeding resumption time was shorter (4 [2-25] vs 7.5 [5-18] days, P <.0001 and 2 [1-15] vs 4 [1-14] days, P <.0001). Three mucosal tears necessitated conversion to open surgery (6%). The rates of " excellent" or " satisfactory" results after laparoscopic and open surgery were 92% (n=48/52) versus 93% (n=28/30), and 83% (n=43/52) versus 83% (n=25/30) on overall clinical score. In both groups, the overall clinical score indicated significant improvement during 12-month follow-up. The laparoscopy and open surgery symptomatic gastroesophageal reflux rates were 10% and 7%, respectively.

CONCLUSIONS

Laparoscopic Heller myotomy favorably compares with open surgery regarding dysphagia relief and gastroesophageal reflux rate. Overall clinical score indicates gradual improvement in patient functional status during 12-month follow-up.

[Digestive tract and botulinum toxin]

INTRODUCTION

the aim of this work was to check literature to assess botulinum toxin injection efficacy in gastrointestinal motor disorders with special emphasis on controlled clinical trials.

METHODS

literature was carried out with the Medline data bank.

RESULTS

seventy three articles in French and in English including a recent general review were retained. Comparative clinical trials only concerned achalasia and anal fissure. The other gastrointestinal motor disorders only gave rise to open non-controlled trials assessed on clinical end points.

DISCUSSION

this review of literature helps to determine usefulness and safety of Botulinum toxin injection in the treatment of esophageal achalasia and anal fissure. The main limitation is its brief duration of action. Studies concerning the others spastic motor disorders are based on unknown physiopathology and controlled trials are required to assess its efficacy.

CONCLUSION

botulinum toxin is increasingly used for gastrointestinal motor disorders with worthwhile results. Its efficacy has been yet established for only two disorders : it has a valuable palliative role in achalasia and may be curative for anal fissure.

[Appropiateness of colonoscopy in a gastrointestinal unit in 2001: a prospective study using criteria established by a European panel of experts]

Criteria for appropriateness of colonoscopy have been elaborated by an European Panel (EPAGE).

OBJECTIVES

1) To assess the feasibility of EPAGE criteria in clinical practice, 2) to assess colonoscopy appropriateness using EPAGE criteria, 3) to compare colonoscopy appropriateness and findings.

PATIENTS AND METHODS

Four hundred and six consecutive examinations were included. The referral indication was judged using a scoring system on the basis of the EPAGE criteria.

RESULTS

Appropriateness could be assessed in 94% of the colonoscopies. Fifty-four percent were appropriate, 40% equivocal, and 6% inappropriate. Rate of abnormal colonoscopy was not different between the 3 groups, however endoscopic findings were more severe when the indication was appropriate. In the appropriate group, adenomatous polyps were more frequent (24%) than in the two other groups (13% and 12%; P<0.05) and tended to be larger in size. In the inappropriate group, patients were significantly younger, and no cancer was found. There were 5 colonic cancers in the inappropriate group and 12 in the appropriate group.

CONCLUSION

Colonoscopy is generally not overused according to EPAGE guidelines. However, on an individual basis it could be rather difficult to determine colonoscopy appropriateness using a scoring system. Indeed, a third of the indications was judged equivocal and the endoscopic findings were no different whether indication was appropriate or equivocal.

[Conservative management of esophageal perforation after pneumatic dilatation for achalasia]

PURPOSE

To assess the results and indications of conservative management of esophageal perforation following pneumatic dilatation for achalasia.

PATIENTS AND METHODS

Thirteen esophageal perforations complicating 524 dilatations in 412 patients (3%) were diagnosed by esophagogram. Medical treatment consisted of nasogastric succion, antibiotics and pleural drainage, if necessary. Conservative surgical treatment included left thoracophrenotomy, perforation closure, controlateral myotomy and anterior fundoplication. Surgical decision was based upon clinical and radiological parameters. Functional outcome was assessed by the means of the Eckardt's grading score.

RESULTS

Six patients were successfully managed by medical treatment. Seven patients underwent conservative surgery, three of whom after failure of medical treatment. The presence of a pneumomediastinum at initial presentation led to immediate (n=2) or delayed (n=2) surgery in all instances. No patients died. In the surgical group, morbidity consisted of one wound infection, one pleural effusion and one venous thrombosis. One severe chest infection occurred in the medical group. Oral feeding was reintroduced after a median of 10 and 11 days in the surgical and medical groups, respectively. Functional results were satisfactory and similar in both groups.

CONCLUSION

Conservative medical or surgical management of oesophageal perforation following pneumatic dilatation is safe, if the diagnosis is done early. Pneumomediastinum at initial presentation seems to predict failure of conservative medical treatment.

Assessment of hypothalamic-pituitary-adrenal axis function after corticosteroid therapy in inflammatory bowel disease

OBJECTIVES

In patients with inflammatory bowel disease (IBD), little is known about the effect of long term corticosteroid therapy (CT) on the hypothalamic-pituitary-adrenal (HPA) axis function. Our aim was to assess HPA axis function in IBD, before the end of CT, during the tapering phase.

METHODS

HPA axis function was assessed with cortisol (ng/ml) measurement before (T0) (normal > 100) and 60 min (normal > 210) after 0.25 mg tetracosactide (Synacthen immédiat) injection (T60) in 55 consecutive cases of IBD attacks. Abnormal response was defined as a T60 <210. The attacks were separated into two groups according to the result of the Synacthen test (ST).

RESULTS

In all, 36 of 55 ST were abnormal. The time for recovery normal HPA axis function was 7.2+/-1.3 months. Duration of disease since onset, past history of surgical or immunosuppressive treatment, severity and extension of the attack, need for surgical or immunosuppressive treatment, total cumulative and mean daily corticosteroid dose, total duration of CT, and steroid dose at the time of ST were not significantly different in the two groups. In multivariate analysis a past history of CT was predictive of abnormal ST (OR = 8.4, 95% CI = 2.2-31.5, p = 0.0009). Among patients with a past history of CT, the time (months) elapsed between the last course of CT was significantly longer in those with normal ST than in those with abnormal ST (45.5+/-13.5 vs 15.4+/-6.0; p = 0.02), and in multivariate analysis a duration free of CT < 15 months was predictive of abnormal ST (OR = 15.00, CI = 1.23-183.00, p = 0.03).

CONCLUSIONS

In all, 65% of the ST were abnormal. These results suggest that ST should be performed before corticosteroid withdrawal, especially in patients with recent past history of CT.

[Percutaneous endoscopic gastrostomy in elderly patients. A prospective study in a geriatric hospital]

OBJECTIVES

The purpose of this work was to search for prognostic factors after percutaneous endoscopic gastrostomy (PEG) for enteral nutrition in geriatric patients by studying complications, nutritional benefits, and impact on quality of life.

METHODS

In this prospective study, 59 elderly patients referred for PEG were followed for 1 year or until tube removal or death. Complications, tolerance to enteral nutrition, nutritional status, infection, bedsores and quality of life were assessed by a questionnaire at tube insertion, at 1 month and every 3 months. Multivariate analysis was performed to look for factors predictive of early mortality before one month.

RESULTS

Insertion of the PEG tube was always successful. Pneumonia in the week before tube insertion was predictive of early mortality (odds-ratio: 8.77 [1.63-47.2], P=0.01). Thirty-day mortality was 25%, but was never related to PEG tube insertion. During follow up, no local complication was observed and enteral feeding was well tolerated. After 3 months, serum albumin and prealbumin levels increased (P<0.001). There were fewer infections (P<0.001) and bedsores remained unchanged. Quality-of-life scores were not modified. At one year, the PEG tube was removed in 16 patients who resumed normal oral nutrition, and 6 other patients were able to return to their home.

CONCLUSION

In a cohort of aged institutionalized patients, PEG for enteral nutrition was well tolerated and not definitive in more than one-quarter of them. Active lung infection is a risk factor of early mortality.

Long-term outcome of patients with gastrointestinal bleeding of obscure origin explored by push enteroscopy

BACKGROUND AND STUDY AIMS

Little is known of the long-term outcome in patients with gastrointestinal bleeding of obscure origin, who undergo investigation by means of push enteroscopy. The aim of this study was to assess the rate of recurrent bleeding and its predictive factors in patients with gastrointestinal bleeding of obscure origin, after exploration by push enteroscopy.

PATIENTS AND METHODS

105 patients with gastrointestinal bleeding of obscure origin (iron-deficiency anemia: n = 56; overt bleeding: n = 49) underwent exploration by push enteroscopy from December 1994 to December 1998. They were classified into three groups according to enteroscopy findings: no lesion found (group A; 56 patients), arteriovenous malformations (group B; 18 patients), and other gastrointestinal lesions (group C; 31 patients). Actuarial rates of rebleeding during follow-up were calculated and factors associated with rebleeding were assessed by means of univariate and multivariate analysis.

RESULTS

Follow-up data were obtained for 101 patients (96 %). The mean follow-up was 29 months (6 - 54 months). The 2-year actuarial rate of rebleeding was 31 % in the overall population, and 27.6 %, 56 % and 24 % in groups A, B, and C, respectively (P = 0.13). The number of previous bleeding episodes and the number of packed red cell units transfused were two independent factors predictive of recurrent bleeding. The modality of recurrent bleeding (anemia or overt bleeding) was similar to that of the initial episode in 94 % of cases. In group A, a gastrointestinal lesion was found after rebleeding in one of the 12 patients with iron-deficiency anemia, and in four of the five patients with overt bleeding.

CONCLUSION

Recurrent bleeding occurs in about one-third of patients who undergo investigation by push enteroscopy for gastrointestinal bleeding of obscure origin, with a trend towards more frequent rebleeding in patients with arteriovenous malformations. Frequent previous bleeding episodes and transfusion requirements are predictive of recurrent bleeding.

Results of pneumatic dilatation in patients with dysphagia after antireflux surgery

BACKGROUND

The mechanisms and treatment of persistent dysphagia after antireflux surgery are not well established. The results of pneumatic dilatation were evaluated in a retrospective study.

METHODS

Sixteen patients were reviewed. All had severe and persistent postoperative dysphagia evaluated by oesophageal manometry before pneumatic dilatation.

RESULTS

Seven patients had one dilatation and nine had two dilatations. There was no complication and no relapse of reflux symptoms. Results were satisfactory in nine patients (mean(s.e.m.) follow-up 19.2(6.9) months) and poor in seven, who required revisional surgery. Age, time since operation and weight loss were not related to the outcome. Thirteen patients had abnormal manometry with an 'achalasia-like' motor pattern in four. Lower oesophageal sphincter (LOS) pressure, LOS relaxation and oesophageal contraction amplitude were similar in the two groups. The only difference was in the percentage of normal peristaltic contractions (mean(s.e.m.) 82.2(11) versus 39.1(13.8) per cent for satisfactory and poor results respectively; P < 0.05).

CONCLUSION

In this retrospective study pneumatic dilatation was effective and safe in nine of 16 patients with dysphagia following antireflux surgery. Peristalsis was normal in eight patients, in seven of whom it was associated with satisfactory results.

[Dysphagia in a trisomic adult operated on for esophageal atresia: achalasia or pseudo-achalasia?]

Esophageal involvement is frequent in Down syndrome. We report a case of dysphagia in a 21-year-old patient with Down syndrome and repaired esophageal atresia. Radiology, endoscopy, and manometry showed typical features of achalasia. The patient was treated first by botulinum toxin injection and afterwards by Heller myotomy with good result. The role of motor disorders associated with esophageal atresia or with primary achalasia in this patient is discussed.

Technetium Tc 99m hexamethyl propylene amine oxine leukocyte scintigraphy in patients with ulcerative colitis: correlation with clinical, biologic, endoscopic, and pathologic intensity, and local release of interleukin 8

BACKGROUND

Technetium Tc 99m hexamethyl propylene amine oxine (99mTc-HMPAO) has been used to radiolabel leukocytes with promising results for its clinical use in inflammatory bowel disease. During active ulcerative colitis, colonoscopy is indicated to determine the extent and the intensity of the disease for proper management. The aim of this prospective study was to determine whether 99mTc-HMPAO-labeled leukocyte scintigraphy can give information similar to that obtained with colonoscopy during acute attacks of ulcerative colitis.

METHODS

Thirty-three consecutive patients with 50 acute episodes of ulcerative colitis underwent 99mTc-HMPAO scintigraphy and colonoscopy with biopsies. Scintigraphic determination of disease extent and intensity were compared with those obtained by colonoscopy with biopsies and clinicobiologic markers.

RESULTS

The scintigraphic index of disease intensity was correlated with endoscopic index, Truelove index, biologic markers, and local release of interleukin-8. The extent measured by scintigraphy was well correlated to the endoscopic and histologic extent.

CONCLUSIONS

99mTc-HMPAO scintigraphy accurately determines the extent and the intensity of acute ulcerative colitis lesions. This noninvasive method can specify the extent and the intensity of an acute attack in patients with previously known ulcerative colitis.

[Comparison of push-type endoscopy and barium transit study of the small intestine in digestive bleeding and unexplained iron-deficiency anemia]

OBJECTIVES

A radiological examination of the small bowel is often performed in case of gastrointestinal bleeding of obscure origin. More recently, push-type enteroscopy has been reported as a valuable tool in this indication. The purpose of this study was to compare the diagnosis efficiency of these two procedures.

METHODS

From February 1994 to February 1996, 40 patients (mean age: 52 years) with obscure gastrointestinal bleeding (iron-deficiency anemia without obvious cause of blood loss or malabsorption: n = 17; macroscopic gastrointestinal bleeding: n = 23) were examined by small bowel follow-through and push-type enteroscopy (jejunoscopy n = 19; double way examination n = 21). Each patient had negative upper and lower gastrointestinal tract endoscopies prior to small bowel examinations.

RESULTS

Small bowel follow-through revealed only one lesion potentially responsible for blood loss (2.5%), corresponding to a jejunal leiomyoma. Push-type enteroscopy detected small bowel lesions potentially responsible for blood loss in 6 patients (15%). The lesions were located in the jejunum in 5 cases (arteriovenous malformations: n = 3; metastasis: n = 1; leiomyoma: n = 1), in the ileum in 1 case (leiomyoma). The efficiency of push-type enteroscopy for the detection of a small bowel lesion was of 22% in case of macroscopic bleeding and of 6% in case of iron-deficiency anemia. Push-type enteroscopy also revealed lesions previously undetected by gastroscopy or colonoscopy in 8 patients (20%).

CONCLUSION

Push-type enteroscopy was more effective than small bowel follow-through to detect the origin of obscure gastrointestinal bleeding. Push-type enteroscopy revealed a cause of bleeding in 35% of patients, located in the small bowel in only 15% of the patients.

Diagnostic yield of push-type enteroscopy in relation to indication

BACKGROUND

Push-type enteroscopy, a recent method for investigating the small intestine, is currently undergoing assessment. Its diagnostic yield varies in the studies reported to date.

AIM

To assess the diagnostic value of push-type enteroscopy according to indication.

PATIENTS AND METHODS

From January 1994 to September 1995, 152 consecutive patients (mean age 34 years) underwent push-type enteroscopy (jejunoscopy, n = 93; retrograde ileoscopy, n = 17; and double way enteroscopy, n = 42). The indications were: unexplained iron deficiency anaemia or macroscopic gastrointestinal bleeding (n = 76), radiological abnormalities of the small intestine (n = 23), chronic diarrhoea and/or malabsorption syndrome (n = 18), abdominal pain (n = 12), and miscellaneous (n = 23). All patients had undergone previous negative aetiological investigations.

RESULTS

The jejunum and ileum were explored through 120 cm (30-160 cm) and 60 cm (20-120 cm). Digestive bleeding: lesions of the small bowel were found in 6% of the patients with isolated iron deficiency anaemia and 20% of patients with patent digestive haemorrhage. Radiological abnormalities of the small intestine: push-type enteroscopy provided a diagnosis or modified the interpretation of radiological findings in 18/23 cases (78%). Chronic diarrhoea and/or malabsorption: push-type enteroscopy yielded explanatory findings in four cases (22%). Abdominal pain: push-type enteroscopy provided no diagnosis.

CONCLUSION

In this series, push-type enteroscopy was of particular value in investigating patients with radiological abnormalities of the small intestine. It was of some value in the exploration of patent digestive haemorrhage or chronic diarrhoea, but not of abdominal pain. Its value was limited in the exploration of iron deficiency anaemia.

Biliary obstruction caused by portal cavernoma: a study of 8 cases

BACKGROUND/AIMS

Biliary obstruction secondary to portal cavernoma is a rare and little-known entity. From 1985 to 1994, we observed eight cases of portal cavernoma compressing the biliary tract. We report here the features of biliary involvement in these cases of portal cavernoma including the circumstances of diagnosis, biliary tract morphology, liver pathology and the efficiency of various treatments.

METHODS AND RESULTS

The causes of portal vein obstruction were portal vein thrombosis in one case, peritonitis in another, omphalitis in two cases, portal vein catheterization in one case and unknown in two cases. The portal cavernoma was revealed through esophageal varices ruptures in four patients. The mean time from portal cavernoma diagnosis to biliary involvement was 8 years (range 0-21). Six patients had acute cholangitis, one of whom revealed portal vein obstruction. All the patients had abnormal liver function tests. Imaging techniques (transparietal abdominal ultrasonography and abdominal computed tomography scan [n = 8], endosonography [n = 5] and endoscopic retrograde cholangiography [n = 7]) showed in all cases an extraluminal obstacle, laminating the common bile duct. Pathologic examination of the liver showed secondary biliary cirrhosis in one patient, periportal and perisinusoidal fibrosis in another and no abnormalities in three other cases. Three patients were treated by endoscopic sphincterotomy but cholangitis persisted in two cases, leading to death in one. One patient who underwent a splenorenal shunt was symptom-free 60 months after surgery. Balloon endoscopic dilatation of the common bile duct, performed in one case, led to normalization of liver biological tests. The patients with abnormal liver pathology were treated by propranolol and ursodesoxycholic acid. No complication had occurred after 6 and 24 months of follow-up.

CONCLUSIONS

In conclusion, eliminating biliary obstruction seems to be essential in providing the best change of survival for patients when biliary obstruction becomes symptomatic. In cases of abnormal liver pathology, associating propranolol with ursodesoxycholic acid would seem to be useful.

Risk factors of oesophageal perforation during pneumatic dilatation for achalasia

BACKGROUND/AIMS

Pneumatic dilatation of the oesophagus is a well established treatment for achalasia. Oesophageal perforation is the most serious complication that occurs in 2% to 6% of cases. The aim of this retrospective survey was to identify predictive risk factors for perforation in a consecutive series of 218 patients with achalasia.

METHODS

Between 1983 and 1993, 270 pneumatic dilatations were performed in 218 patients. A Witzel dilator was used in 58 cases and a Rigiflex dilator in 212. Eight oesophageal perforations occurred (3%). The clinical, radiological, endoscopic, manometric, and technical data for the eight perforated patients were compared with those of 30 patients randomly sampled among those without perforation.

RESULTS

All perforations occurred during the first dilatation. Perforations were fewer during dilatations with the Rigiflex dilator than with the Witzel dilator (2.4% v 5.2%). Perforations were all located above the cardia, on the left side of the oesophagus. In a multivariate analysis, a small weight loss and a high amplitude of oesophageal contractions in the group of patients with perforations were predictive of complications (respectively, p = 0.001 and p = 0.026). A contraction amplitude higher than 70 cm H2O in the lower part of the oesophagus was observed in three of eight patients with perforations but was not seen in any of the 30 patients without perforation (p < 0.01).

CONCLUSIONS

This identification of risk factors should facilitate the choice between pneumatic dilatation or a surgical approach.