Endoscopic treatment of chronic radiation proctopathy

Radiation proctopathy can be a disabling delayed outcome of radiation therapy directed at pelvic malignancies. Rectal outlet bleeding can be severe enough to result in anemia and transfusion dependency. Bleeding typically develops from 6 months to 1 year after completion of radiation therapy and is caused by friable mucosal angioectasias. Although many approaches to controlling bleeding from chronic radiation proctopathy have been attempted, ranging from topical enema formulations to surgical diversion of the rectum, endoscopic coagulation therapy remains the most effective. This review provides the background issues surrounding the development of chronic bleeding radiation proctopathy and focuses on endoscopic methods of treatment.

Esophagogastric hematoma mimicking a malignant neoplasm: clinical manifestations, diagnosis, and treatment

Esophagogastric hematoma is a rare condition occurring spontaneously or after esophageal instrumentation. In this report, we describe a patient with acute dysphagia in whom a lower esophageal mass was detected radiographically. Upper endoscopy revealed an esophageal mass that extended from the mid-esophagus to the gastroesophageal junction and was associated with a malignant-appearing ulcerated mass (5 to 6 cm) in the cardia. Gastric cancer with esophageal extension was the presumptive diagnosis. Computed tomography showed that the esophageal mass had a density similar to blood, a finding suggesting the presence of an esophageal hematoma. Biopsy specimens of the ulcer revealed acute inflammation but no malignant involvement. The patient was treated conservatively, and the initial symptoms resolved. Esophagogastric hematomas can mimic a neoplasm; thus, establishing the correct diagnosis is important because this condition has a favorable prognosis, and only conservative treatment is needed.

The American College of Gastroenterology Bleeding Registry: preliminary findings

OBJECTIVES

The American College of Gastroenterology (ACG) Institute for Clinical Research and Education conducted a survey study to assess demographics, management strategies, and outcome for patients with gastrointestinal bleeding. This pilot project was intended to determine the feasibility of surveying the ACG membership about common clinical issues.

METHODS

Color-coded survey forms were sent to all ACG members and Fellows, with instructions to supply information about demographics, presenting symptoms, management, and outcome for bleeding patients and procedure-matched controls. Forms returned between June 1 and August 31, 1995, were tabulated and analyzed for differences between the bleeding group and procedure-matched controls.

RESULTS

A total of 1235 forms were returned by respondents, 60% of whom were in private practice. Patient demographics indicated that bleeding patients were significantly older, more likely to be male, and more likely to use alcohol, tobacco, and prescription or over-the-counter aspirin or nonsteroidal anti-inflammatory drugs and anticoagulants than were controls. Upper GI bleeding accounted for 76% of bleeding events, with duodenal and gastric ulcers being the source in more than 50% of the upper GI bleeders. Diverticula was the most common bleeding source identified in lower GI bleeders. In the bleeding group, 78.8% were anemic, with 60.9% having hemoglobin of <10 g/dl; 31% presented with orthostatic changes in blood pressure or shock. Most bleeding subjects, regardless of source, were hospitalized, 58.2% received blood transfusions, and 45.5% received endoscopic therapy. Rebleeding (11.2%), need for surgery (7.1%), and fatalities (2.1%) were uncommon. Over-the-counter aspirin and nonsteroidal anti-inflammatory drugs were used significantly more often in the bleeding population (47.6%) than in controls (19.4%).

CONCLUSIONS

The success of the GI Bleeding Registry supports the feasibility of surveying ACG members about common clinical problems. Data suggest that ACG members manage sick patients with severe gastrointestinal bleeding who require hospitalization, transfusions, and endoscopic treatment. These preliminary results will serve as an impetus to conduct further survey studies of gastrointestinal bleeding and other common digestive disease conditions.

Clinical and endoscopic risk factors in the Mallory-Weiss syndrome

OBJECTIVES

Although patients with bleeding Mallory-Weiss tears are generally hospitalized, we wished to develop guidelines facilitating the selection, by clinical and endoscopic criteria, of patients who do not need hospitalization. Our specific aims were to determine whether presenting manifestations of bleeding differed in hemodynamically unstable patients, whether active bleeding or stigmata of bleeding at endoscopy were prognosticators for significant rebleeding, and the outcomes in endoscopically managed patients.

METHODS

The endoscopic and clinical features of all patients with acute GI bleeding from a Mallory-Weiss tear were obtained from our GI Bleeding Team database over a consecutive 4-yr period and analyzed for prognostic indicators.

RESULTS

1) Presenting manifestations, e.g., hematochezia, were significantly different in hypotensive patients. 2) Active bleeding but not stigmata was associated with higher transfusion requirements. 3) Rebleeding was unusual, occurring within 24 h, more often in patients with a bleeding/coagulation diathesis. The median hospital stay was 4 days (range 1-24). Fifty-seven percent of patients received transfusion (median 4 units, range 1-26 units); requirements were higher in patients with coagulopathies.

CONCLUSIONS

Patients without risk factors for rebleeding (portal hypertension, coagulopathy), clinical features indicating severe bleeding (hematochezia, hemodynamic instability), or active bleeding at endoscopy can be managed with a brief period of observation. Patients with endoscopically active bleeding may benefit from endoscopic therapy.

Sonde enteroscopy. Technique, depth of insertion, and yield of lesions

Sonde enteroscopy provides the only opportunity to directly view the contents and mucosa of potentially the entire small intestine. Although the instrumentation and technique are less than ideal, sonde enteroscopy can be a useful adjunct to the evaluation of small intestinal disease. A comprehensive review of this labor-intensive procedure from patient selection to its outcome is provided in this article.

Endoscopic decompression for acute colonic pseudo-obstruction

BACKGROUND

Acute colonic pseudo-obstruction is often treated by colonoscopic decompression. Efficacy, safety, and outcome of endoscopic decompression was assessed.

METHODS

Colonoscopic decompressions from 1988 to 1994 were reviewed. Resolution without further endoscopic intervention was defined as clinical success.

RESULTS

Acute colonic pseudo-obstruction was diagnosed in 50 patients. Thirty-three cases followed surgery or trauma and 17 developed during severe medical illness. Orthopedic joint surgery was most common. Nineteen of 50 patients (38%) had severe underlying medical disease. Forty-one patients (82%) had one colonoscopic decompression with clinical success in 39 (95%). Nine patients (18%) required multiple (2 to 4) colonoscopic decompressions with clinical success in 5 (56%). A decompression tube positioned in the right colon (57%) and in the transverse colon (33%) had similar clinical success. In 8 procedures a decompression tube was not placed, with poor clinical success (25%). The overall clinical success of colonoscopic decompression was 88% (44 of 50). An endoscopic perforation occurred in 1 patient (2%). Overall hospital mortality was 30%.

CONCLUSIONS

Colonoscopic decompression is effective and safe for acute colonic pseudo-obstruction that does not respond to conservative therapy. Most patients will respond to one colonoscopic decompression with decompression tube placement. Complete colonoscopy and cecal tube placement is unnecessary.

The risk of withdrawing chronic anticoagulation because of acute GI bleeding

OBJECTIVE

We sought evidence for thromboembolic sequelae after the transient withdrawal of chronic anti-coagulation because of acute GI bleeding.

METHODS

Our Gastrointestinal Bleeding Team endoscopic database was reviewed over a 5-yr period to identify patients who underwent a transient withdrawal from chronic anticoagulation as a result of acute GI bleeding. Long term follow-up records were available for all study patients and were carefully scrutinized for any symptomatic thromboembolic events.

RESULTS

Twenty-seven patients were included in the study, of which 17 (63%) were on chronic anticoagulation for prosthetic heart valves. Chronic anticoagulation was withheld for a median period of 3 days (range = 2-7 days) for patients with prosthetic heart valves and 7 days (range = 2-15 days) for patients on chronic anticoagulation for other indications. Over a median follow-up period of 8 months (range = 1-54 months), one patient developed documented lower extremity thromboembolism.

CONCLUSIONS

We conclude that symptomatic thromboembolism can occur after the transient withdrawal of chronic anticoagulation for acute GI bleeding but that it does not occur frequently.

Endoscopic treatment of ampullary adenomas in familial adenomatous polyposis

Duodenal adenomas, usually considered premalignant, are found in < or = 100% of patients with familial adenomatous polyposis (FAP). Endoscopic screening is accepted, but the optimal treatment is unclear. Our objective was to assess endoscopic treatment of the upper gastrointestinal tract in patients with FAP. We reviewed the clinical records of 393 FAP patients in detail. Six patients had ampullary cancers. Sixty-nine had periampullary adenomas, none of whom developed malignancy during follow-up. Several endoscopic approaches were used, leading to various outcomes. (a) Follow-up with ampullary biopsy was the only method in 18 patients, with macroscopic improvement in one, unchanged condition in 11, and enlargement of adenomas in six. (b) Thermal ablation was used in 19 patients, with resolution in 10, improvement in seven unchanged condition in one, and one recurrence. (c) Yearly push enteroscopy, duodenoscopy, and ampullary biopsies were conducted in 11 of the 19 patients treated first with thermal ablation. Positive biopsies resulted in endoscopic retrograde cholangiopancreatography (ERCP), prophylactic sphincterotomy, and ablation with reexamination every 2-6 months. Follow-up of the patients treated with this last and favored strategy showed that five experienced resolution of symptoms, five had macroscopic improvement, and one had macroscopic as well as histologic progression. We conclude that patients with FAP should have periampullary surveillance, including duodenoscopy and biopsies from the time of diagnosis. Periampullary adenomas can be eradicated endoscopically. It is not clear whether ablation of adenomas or periodic biopsy is the ideal treatment.

Development of hyperplastic polyps following laser therapy for watermelon stomach

BACKGROUND

Our goal was to evaluate the long-term sequelae of repeated thermal injury to the gastric mucosa of patients undergoing laser therapy for watermelon stomach.

METHODS

A retrospective review of all patients who underwent endoscopic laser therapy for watermelon stomach from 1987 to 1994 was performed to identify patients with antral polyps following laser photoablation therapy. Statistical analysis was performed using the paired t test.

RESULTS

Antral hyperplastic polyps as large as 4 cm developed in 4 of 60 patients (7%) and were associated with recurrent anemia in 3. All patients had received significantly more laser thermal energy during the course of therapy for their watermelon stomach. Conventional polypectomy was used to remove the polyps.

CONCLUSIONS

Repeated thermal injury to the antral mucosa in patients with the watermelon stomach may result in the development of hyperplastic polyps. These may be large, may contribute to significant blood loss with anemia, and are amenable to conventional polypectomy.

The black esophagus

A dark-pigmented (black) esophagus is a rare observation during the course of upper endoscopy. The differential diagnosis of a black esophagus includes acute necrotizing esophagitis, exogenous dye ingestion, lye ingestion, malignant melanoma, melanosis, and pseudomelanosis esophagi. Many of these conditions are suggested by the history and associated endoscopic findings. In most patients, a biopsy is needed to establish a definitive diagnosis and explanation for the black-appearing esophagus. We describe a patient with a black esophagus encountered during routine endoscopy. The clinical, endoscopic, and histopathological features of this unusual finding are presented, along with a review of the literature.

Infrared video imaging of subsurface vessels: a feasibility study for the endoscopic management of gastrointestinal bleeding

The feasibility of infrared video imaging of subsurface vessels in the stomach was investigated both experimentally and in more detail using computer simulations of light propagation. Infrared video imaging was first attempted in several experimental situations. Images of a human arm illuminated with infrared light (wavelength > 700 nm) revealed subcutaneous venous structures not revealed by visible light (wavelength of 500 to 600 nm). An infrared-sensitive video endoscope was used to view both a human arm and normal stomach wall. Infrared illumination within the stomach enhanced only the larger subsurface vessels. Infrared transillumination of a rat skin flap window chamber allowed video recording of images during injection of an absorbing dye, indocyanine green, into the blood volume and showed that indocyanine green can enhance the contrast in infrared images of small vessels. Computer simulations of vessels of varying depths and sizes indicated successful detection was possible by infrared imaging. Computer simulations demonstrated that the shadow caused by an imaged subsurface vessel has two characteristics: (1) the central loss of reflectance, which indicates the size of the vessel, and (2) the full-width half-maximum of the reflectance loss, which indicates the depth of the vessel. The simulations further suggested that images of small vessels can be dramatically enhanced (68-fold) by indocyanine green, which attenuates the transmittance of scattered light from behind the vessels to the surface for observation. On the other hand, indocyanine green enhances the contrast of large vessels to a lesser degree (2.6-fold). The ultimate goal is to develop an endoscopic video imaging system capable of capturing reflected light from the stomach wall.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of therapeutic endoscopy on the treatment of bleeding duodenal ulcers: 1980-1990

Therapeutic endoscopy (TE) has provided a new means for treating peptic ulcer disease, prompting a reevaluation of surgery's role. The aim of this study was to determine if surgical therapy of bleeding duodenal ulcers has changed since the advent of TE. This retrospective review involved consecutive time periods during which TE was (1985-1990) and was not (1980-1984) widely available. Exclusion criteria were prior gastric surgery, nonpeptic conditions, and untreated ulcers. Inclusion standards were met by 252 patients (180 men, 72 women) whose mean age was 67 years. Patients were grouped by the initial therapeutic intervention. Groups were similar in age, medical condition (mean APACHE II score 16), and morbidity. Seventy-five patients had surgery alone during 1980-1984 and 38 during 1985-1990. TE was initially performed on 134 patients during 1985-1990. Bleeding (n = 30) and perforation (n = 1) prompted emergent operation in 23% of cases following TE. Thus 69 (38 + 31) patients underwent surgery between 1985 and 1990. Preprocedure transfusions averaged 4.1 units in the endoscopic group and 8.2 units in the operative groups (p < 0.0001). Disagreement existed between the endoscopic and surgical descriptions of ulcer location in 53% of cases. Emergent surgery was required in 45% of hemodynamically unstable patients versus 14% of stable patients who initially underwent TE (p < 0.0001). Sixty-one percent of incompletely visualized TE-treated lesions required operation, and 18% of well visualized ulcers underwent operation (p < 0.0001). Hospital mortality was similar (8% versus 16%) in the endoscopic and operated groups (p = 0.7). Mean follow-up was 540 days.(ABSTRACT TRUNCATED AT 250 WORDS)

Bleeding from the endoscopically-identified Dieulafoy lesion of the proximal small intestine and colon

OBJECTIVES

Our goal was to assess the incidence of the endoscopically-identified small intestinal and colonic Dieulafoy-like lesions in our GI bleeding population and to characterize the clinical and endoscopic features and response to endoscopic therapy.

METHODS

Patients with GI bleeding from Dieulafoy lesions were identified from our Bleeding Team and GI laser data bases from August 1984 to September 1993. Clinical and endoscopic information contained within the data bases and from each patient's medical record were retrospectively reviewed. Diagnostic criteria that had been used to endoscopically diagnose a Dieulafoy lesion were arterial bleeding or nonbleeding visible vessel stigmata, all without ulceration or erosion.

RESULTS

Nine patients (three male; six female; median age, 70 yr; range, 16-94) were identified from a population of 3059 patients. Symptoms included: melena (2); hematochezia (7); and unstable hemodynamics (3). The mean hemoglobin was 8.4 +/- 2.2 g/dl. There was no significant nonsteroidal antiinflammatory drug or alcohol use. Four patients had small bowel and five patients had colonic Dieulafoy's lesions. Specific sites were: distal duodenum (3); jejunum (1); cecum (1); hepatic flexure (3); and transverse colon (1). The diagnosis was made at initial endoscopy in seven patients, after two endoscopies in one patient, and after four in another patient. Active bleeding was encountered in seven patients (three small bowel; four colon). Endoscopic therapy was successful. Two patients rebled, one from the same site (small bowel) 1 yr later. Both were successfully retreated. There were no complications or deaths.

CONCLUSIONS

The endoscopic Dieulafoy lesion of the small bowel and colon is infrequently encountered. The diagnosis is most often made during active bleeding. The endoscopic diagnosis requires an aggressive approach, including repeated endoscopy. Endoscopic therapy of proximal small intestinal and colonic Dieulafoy lesions is safe, effective, and should be performed.

Does performance status influence the outcome of Nd:YAG laser therapy of proximal esophageal tumors?

The value of endoscopic palliative therapy for malignant obstruction in the proximal esophagus has been questioned. To assess the importance of pre-treatment performance status on treatment outcome, we reviewed the records of patients with tumors of the proximal esophagus undergoing endoscopic laser therapy between January 1986 and December 1988. As compared with 10 patients having a good performance status, eight patients with a poor performance status had a lower frequency of obtaining complete functional relief of dysphagia (14% versus 71%), an increased rate of complications (50% versus 0%), and a shorter median survival time (24 days versus 161 days). We conclude that performance status should be considered in determining the appropriateness of laser therapy in patients with proximal esophageal cancer.

Acute gastrointestinal bleeding from portal hypertensive gastropathy: prevalence and clinical features

The clinical and endoscopic features of patients diagnosed with acute bleeding due to portal hypertensive gastropathy (PHG) were evaluated. Acute bleeding from PHG was diagnosed in 12 patients (0.8%) of 1496 patient admissions prospectively evaluated by our Gastrointestinal Bleeding Team over a 3-yr period, and accounted for 8% of nonvariceal bleeding diagnosed in patients with liver disease. The median age of PHG patients (8M:4F) was 66 yr (range, 37-72). The most common underlying liver disease was alcoholic cirrhosis (five patients). The majority of patients presented with melena. There was no hemodynamic instability. Six patients had prior sclerotherapy. Esophageal varices, grades 1 (five patients) and 2 (three patients), were present. Severe PHG was encountered in seven patients. There was no correlation between the presence or absence of varices, the grade of esophageal varices, and prior sclerotherapy on the severity of PHG or continued bleeding. The mean hospital stay was 6 days. An average of 4 units of blood was transfused per patient (range, 2-8). Continued bleeding occurred in nine patients (75%), one of whom had mild PHG. Two patients with continued bleeding subsequently were diagnosed with portal hypertensive vasculopathy distal to the stomach. There was one episode of encephalopathy and no related mortality. Acute (overt) bleeding from PHG is uncommon, likely to recur, and can evolve into a pattern of chronic blood loss.

Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon

Endoscopic laser coagulation effectively controls bleeding from radiation-induced rectal vascular lesions.

OBJECTIVE

To assess the outcome of endoscopic treatment of radiation-induced bleeding due to vascular lesions located proximal to the sigmoid colon.

METHODS

We identified 15 consecutive patients with such proximal radiation enteropathy treated at our Institution with Nd:YAG laser between 1984 and 1991. Ten patients (66%) had gastric and/or small bowel involvement, and five (33%) had colonic involvement with or without more proximal lesions. Bleeding first appeared at a mean of 21.2 +/- 12.5 months after completion of radiotherapy. Mean duration of gastrointestinal bleeding before laser treatment was 7.6 +/- 4.6 months.

RESULTS

After completion of laser therapy, bleeding ceased in nine (60%) patients, decreased in three (20%), and persisted in three (20%). The mean hemoglobin level increased from 8.4 +/- 0.5 g/dl to 10.4 +/- 0.6 g/dl after completion of laser treatments (p < 0.02). The mean number of transfusions per patient per year decreased from 10.5 +/- 2.8 to 0.9 +/- 0.7 (p < 0.01). No treatment-related complications or deaths occurred.

CONCLUSIONS

Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon appears to be safe and, in most cases, effective.

Endoscopic Nd:YAG laser coagulation of bleeding from radiation proctopathy

Hematochezia from mucosal vascular lesions usually confined to the rectum represents an uncommon but problematic late complication of pelvic radiotherapy. We studied 47 patients with medically refractory hematochezia resulting from radiation-induced rectosigmoid mucosal vascular lesions. All lesions were endoscopically coagulated with Nd:YAG laser. Median duration of hematochezia before laser therapy was 11 months, despite previous medical treatment (98%) or bypass colostomy (6%). Within 3 to 6 months after laser treatment, the number of patients with daily hematochezia fell from 40 (85%) to 5 (11%; p < 0.001), and the median hemoglobin level increased from 9.7 gm/dl to 11.7 gm/dl (p < 0.001). Complications occurred in three patients (6%); no deaths occurred. The condition in six patients (12.8%) was not improved by laser treatment. Two patients (4%) ultimately required surgical treatment for bleeding control. On the basis of symptomatic, hematologic, and endoscopic responses, Nd:YAG laser photocoagulation controlled bleeding from radiation proctopathy in most patients with an acceptably low morbidity. Patients with sigmoid colon involvement responded less favorably. Endoscopic laser photocoagulation should be considered before surgical intervention for treatment of hematochezia from radiation proctopathy.

The clinical and endoscopic spectrum of the watermelon stomach

The watermelon stomach is an uncommon but treatable cause of chronic gastrointestinal bleeding. We report our experience with the clinical and endoscopic features of 45 consecutive patients treated by endoscopic Nd:YAG laser coagulation. The prototypic patient was a woman (71%) with an average age of 73 years (range of 53-89 years) who presented with occult (89%) transfusion-dependent (62%) gastrointestinal bleeding over a median period of 2 years (range of 1 month to > 20 years). Autoimmune connective tissue disorders were present in 28 patients (62%), especially Raynaud's phenomena (31%) and sclerodactyly (20%). Atrophic gastritis occurred in 19 of 19 (100%) patients, with hypergastrinemia in 25 (76%) of 33 patients tested. Antral endoscopic appearances included raised or flat stripes of ectatic vascular tissue (89%) or diffusely scattered lesions (11%). Proximal gastric involvement was present in 12 patients (27%), typically in the presence of a diaphragmatic hernia. Endoscopic laser therapy after a median of one treatment (range of 1-4) resulted in complete resolution of visible disease in four patients (13%) and resolution of > 90% in 24 patients (80%). Hemoglobin levels normalized in 87% of patients over a median follow-up period of 2 years (range of 1 month to 6 years) with no major complications. Blood transfusions were not necessary after laser therapy in 86% of 28 initially transfusion-dependent patients. The characteristic clinical, laboratory, and endoscopic features allow for a confident diagnosis that can lead to successful endoscopic treatment.

Clinical features and endoscopic management of Dieulafoy's disease

The experience of a specialized management team using urgent endoscopy in the management of acute gastrointestinal bleeding from Dieulafoy's disease is presented. Dieulafoy's disease was found in 19 of 1124 consecutive patients with upper gastrointestinal bleeding. Most patients with Dieulafoy's disease were elderly men with severe acute upper gastrointestinal hemorrhage. Endoscopic diagnosis was possible in all patients, but required multiple endoscopies in 37%. The lesions were in the proximal stomach (79%) and duodenal bulb (21%). Endoscopic therapy included epinephrine injection, then heater probe coagulation in 17 patients, bipolar electrocoagulation in 1, and Nd:YAG laser photocoagulation in 1. Endoscopic therapy was successful in 18 patients (95%); one patient had successful surgery after endoscopic therapy failed. There were no deaths due to bleeding and no endoscopic complications. Dieulafoy's disease is an unusual cause of acute gastrointestinal bleeding. Endoscopic diagnosis is sometimes difficult, but primary endoscopic therapy is safe, successful, and should be attempted.

Role of endoscopic retrograde cholangiopancreatography after orthotopic liver transplantation

We reviewed the records of 20 liver transplant patients who underwent 28 procedures [endoscopic retrograde cholangiopancreatography (ERCP)] to rule out biliary obstruction, treat bile leaks, dilate and/or stent strictures, or remove stones and debris. Three patients (two with abnormal T-tube cholangiograms and one with hyperbilirubinemia) underwent ERCP to rule out obstruction. Therapeutic ERCP (sphincterotomy with balloon dilatation or stone extraction) was successful in 16 of 17 patients, including seven of nine in whom there was resolution of bile leaks without the use of stents or surgery. Mild pancreatitis occurring in one patient was the only complication experienced that was related to ERCP. We conclude that ERCP is a safe and important modality in the medical management of biliary tract complications after orthotopic liver transplantation.

Portal hypertensive intestinal vasculopathy: a review of the clinical, endoscopic, and histopathologic features

Over the past decade, awareness of the association between portal hypertension and changes in the intestinal circulation has increased. Most of the observations have been made by endoscopic examination and biopsy of the mucosa. The fundamental pathologic change is a vasculopathy. Portal hypertensive intestinal vasculopathy (PHIV) most often involves the stomach (gastropathy) and can be a common source of bleeding. The significance of small bowel involvement (enteropathy) is unknown. Colon involvement (colopathy) has been associated with bleeding, and mimics inflammatory bowel disease. The reliability of endoscopic appearances and histologic examination in establishing the diagnosis is questionable. Recent observations of other diagnostic modalities and associated physiologic alterations and treatment options are discussed. Further prospective evaluations that use uniform terminology for endoscopic and histologic descriptions are needed to establish criteria for accurate diagnosis and assessment of response to treatment.

Acute gastrointestinal bleeding. Experience of a specialized management team

The initial experience of a specialized management team organized to provide expedient care for all acute major gastrointestinal bleeding in protocolized fashion at a large referral center is presented. Of the 417 patients, 56% developed bleeding while hospitalized. Upper gastrointestinal bleeding accounted for 82%. The five most common etiologies included gastric ulcers (83 patients), duodenal ulcers (67 patients), erosions (41 patients), varices (35 patients), and diverticulosis (29 patients). Nonsteroidal anti-inflammatory drugs were implicated in 53% of gastroduodenal ulcers. The incidence of nonbleeding visible vessels was 42% in gastric and 54% in duodenal ulcers. The rates of rebleeding were 24% (20 patients) in gastric ulcers and 28% (19 patients) in duodenal ulcers. Predictive factors for rebleeding included copious bright red blood, active arterial streaming, spurting, or a densely adherent clot. The rebleeding rate for esophagogastric varices was 57%. The mortality rate overall was 6% (27 patients), with rates varying from 3% (five patients) for gastroduodenal ulcers to 40% (14 patients) for esophagogastric varices. The morbidity rate for the entire patient population was 18% (77 patients), dominated by myocardial events (34 patients). The average length of hospitalization for gastroduodenal ulcers was 5 days, for diverticulosis 8 days, and for varices 10 days. The major efforts of a specialized Gastrointestinal Bleeding Team would be best directed at both reducing the morbidity associated with acute bleeding and reducing the overall cost of care.

Small bowel enteroscopy: an early experience in gastrointestinal bleeding of unknown origin

Peroral small intestinal enteroscopy was performed in 35 consecutive patients with gastrointestinal bleeding of unknown origin by using a prototypic Sonde-type enteroscope. The median value for patient age was 69 years; duration of bleeding, 2 years (range, 2 months to 9 years); and transfusion requirements, 9 units. Bleeding was occult in 54% of these patients. Placement and passage of the enteroscope was performed by a gastrointestinal endoscopy assistant. Mean passage time was 4.3 hours. Complete passage was obtained in 14% of the patients, passage into the mid-distal ileum in 69%, and passage only into the jejunum in 17%. The diagnostic yield was 26%, with the majority of lesions encountered being mucosal vascular malformations. Small intestinal enteroscopy is a reasonable diagnostic procedure before embarking on visceral angiography and surgical exploration when standard endoscopic and radiologic methods fail to disclose a diagnosis.

Congestive gastropathy and other upper endoscopic findings in 81 consecutive patients undergoing orthotopic liver transplantation

Pretransplant endoscopic findings in 81 consecutive patients with nonalcoholic liver disease were examined to determine the spectrum of abnormalities encountered, with particular attention to mucosal changes consistent with congestive gastropathy. Abnormalities were observed in 75 patients (93%). Twenty-three patients (28%) had findings suggestive of congestive gastropathy: petechiae, focal and diffuse intense erythema, with or without erosions, edematous mucosa with a fine white reticulated or mosaic pattern, and cherry red spots resembling vascular malformations. Congestive gastropathy was the second most common abnormality identified after esophageal varices (66 patients, 81%). Other abnormalities included gastric varices in 13 patients (16%), esophagitis in seven (9%), gastric ulcers in six (7%), duodenal ulcer in 11 (14%), postsclerotherapy esophageal ulceration in 10 (12%), and a postsclerotherapy symptomatic esophageal stricture in one. The prevalence of congestive gastropathy has provided a stimulus for our prospective evaluation of gastric mucosal disease before and after liver transplantation or portosystemic shunt.

Gastrointestinal laser endoscopy--future horizons

The laser, especially the neodymium:yttrium-aluminum-garnet device, has been a dominant influence on the development of gastrointestinal therapeutic endoscopy. More than 2,000 such procedures were performed in the first 5 years of experience with laser endoscopy at the Mayo Clinic. The major areas for future development are (1) the control of acute and chronic gastrointestinal bleeding, (2) the palliation of malignant gastrointestinal neoplasms, and (3) the management of benign and malignant obstructive lesions of the biliary tract. Refinements in laser devices, delivery systems, and techniques such as photodynamic therapy will be needed to achieve more selective tissue destruction. Improvements in the new adjunctive endoscopic methods of electronic (video) endoscopy and ultrasonography may enhance evolving laser applications by more accurately identifying diseased tissues and guiding their destruction.

Congestive gastroenteropathy--an extension of nonvariceal upper gastrointestinal bleeding in portal hypertension

Three cirrhotic patients with acute and chronic gastrointestinal blood loss are described. All had extensive gastric mucosal changes on endoscopy consistent with congestive gastropathy and also had extensive duodenal and jejunal changes consisting of multiple friable punctate areas of erythema. Two patients had esophageal varices from which bleeding could not be documented. The mucosal abnormalities seen in the small intestine of all three patients were similar to those within the stomach and are thought to represent an extension of congestive gastropathy and to be contributing to the blood loss. We propose that the term "congestive gastropathy" be replaced by a more comprehensive term, "congestive gastroenteropathy." The cause of these mucosal abnormalities remains unclear. Attempts at endoscopic therapy of these extensive abnormalities should be avoided until a greater understanding of the underlying pathophysiology is reached.

Prospective comparison of contact with noncontact Nd:Yag laser therapy for palliation of esophageal carcinoma

Twenty patients with dysphagia due to inoperable esophageal cancer were randomized to receive either contact or noncontact endoscopic laser treatment. Treatment groups were similar with respect to age, dysphagia score, and tumor dimensions. The median number of initial treatment sessions was two in both groups, and the median treatment times per session were 23 min (range, 12 to 55 min) in the contact group and 19 min (range, 5 to 28 min) in the noncontact group. Median dysphagia scores were also similar in both groups 1 month after laser treatment, and no difference was apparent in the duration of palliation. There were no patient complications attributable to laser therapy, but damage to the laser wave guide occurred in three contact sessions and two noncontact sessions. These data suggest no advantage for the contact method of endoscopic Nd:YAG laser palliation of esophageal carcinoma with respect to number of treatment sessions, relief of dysphagia, or occurrence of complications.

Endoscopic gastric vagotomy: a feasibility study using laser in dogs

The aim of this study was to explore the feasibility of an endoscopic approach to gastric vagotomy using the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in dogs. Based on gross and histologic measurements, target zones for endoscopic vagotomy were defined with reference to mucosal side landmarks. Target zones containing the unbranched segments of the major intramural vagal branches were linear and symmetrically located anterior and posterior to the midline of the lesser curvature extending from the level of the esophagogastric junction to the proximal antral border. Because of minimal variability between dogs, this zone could be accessed endoscopically and reliably injured. Unfortunately, it was necessary to produce a nearly full thickness burn to interrupt the deep intramural vagal branches. Despite efforts to control dosimetry, delayed perforations occurred in three of four dogs. We conclude that endoscopic gastric vagotomy using the Nd:YAG laser is not feasible in the dog model because of difficulty controlling the depth of thermal injury. An endoscopic approach to vagotomy remains conceptually appealing because of the predictable location of and accessibility to a target zone.