[Role of pulse oximetric monitoring during gastrointestinal endoscopy. Prospective multicenter study of the Gastroenterology Working Group of the Veszprém Regional Committee of the Hungarian Academy of Sciences (VEAB)]

INTRODUCTION

Recent guidelines recommend routine pulse oximetric monitoring during endoscopy, however, this has not been the common practice yet in the majority of the local endoscopic units.

AIMS

To draw attention to the importance of the routine use of pulse oximetric recording during endoscopy.

METHOD

A prospective multicenter study was performed with the participation of 11 gastrointestinal endoscopic units. Data of pulse oximetric monitoring of 1249 endoscopic investigations were evaluated, of which 1183 were carried out with and 66 without sedation.

RESULTS

Oxygen saturation less than 90% was observed in 239 cases corresponding to 19.1% of all cases. It occurred most often during endoscopic retrograde cholangiopancreatography (31.2%) and proximal enteroscopy (20%). Procedure-related risk factors proved to be the long duration of the investigation, premedication with pethidine (31.3%), and combined sedoanalgesia with pethidine and midazolam (34.38%). The age over 60 years, obesity, consumption of hypnotics or sedatives, severe cardiopulmonary state, and risk factor scores III and IV of the American Society of Anestwere found as patient-related risk factors.

CONCLUSION

To increase the safety of patients undergoing endoscopic investigation, pulse oximeter and oxygen supplementation should be the standard requirement in all of the endoscopic investigation rooms. Pulse oximetric monitoring is advised routinely during endoscopy with special regard to the risk factors of hypoxemia.

[Treatment of extra-esophageal variceal bleeding with cyanoacrylate]

BACKGROUND AND AIMS

Endoscopic obliteration of bleeding extra-esophageal varices using N-butyl-2-cyanoacrylate (Histoacryl) has been validated by several authors. The aim of the present paper is to describe the intravariceal injection technique using cyanoacrylate and to present the own results and complications observed in conjunction with the haemostatic treatment.

PATIENTS AND METHODS

A total of 11 intravariceal injection treatments of N-butil-2-cyanoacrylate were performed in 8 patients (3 males, 5 females, mean age 65.5 years) with extra-esophageal variceal bleeding. In 7 cases the bleeding varices were located in the gastric fundus and in one case the varix was found in the duodenum. Variceal bleeders under subintensive care were treated early electively with 1:1 ratio cyanoacrylate-lipiodol intravariceal injection solutions. The injection needle was inserted trough a standard endoscope.

RESULTS

Early haemostasis was achieved in all patients (11/11) and no early rebleeding occurred. In one case because of repeated episodes of late recurrent bleedings 3 more injection treatments were performed. In another case several hours after the injection a transitional cerebral ischemic attack developed. Injection needle sticking occurred during one treatment. There was no mortality due to acute bleeding while two patients died because of hepatic failure during the follow up period.

CONCLUSIONS

Endoscopic injection of diluted cyanoacrylate and lipiodol appears to be an effective and safe treatment method of the extra-esophageal variceal bleeding. Injection treatment in an early elective fashion can be performed with the standard sclerotherapy equipment.

[Granulomatous hepatitis successfully treated with ursodeoxycholic acid]

The etiology of granulomatous hepatitis is extremely extensive for which the granulomatous reaction induced hepatic inflammation is characteristic. In the majority of cases it is part of a systemic disease but sometimes there is primer hepatic lesion in the background. The 21 year-old Caucasian female patient was taken to hospital having flu-like symptoms and icterus. While searching for the cause of her cholestatic hepatocellular lesion infections, tumors, storage diseases were excluded. However the root cause could not be identified. The histology showed granulomatous reaction, inflammation, intrahepatic bile duct proliferation and micronodular cirrhosis in the liver tissue. Taken it into consideration together with the the clinical picture and the laboratory findings primer sclerosing cholangitis was rendered probable. Her state deteriorated and even the necessity of liver transplantation emerged. The patient was treated with ursodeoxycholic acid which resulted in remission lasting for years now. Two years after the onset of the hepatic disease pancolitis ulcerosa with affection of the ileum terminalis was found in the patient which supports the diagnosis of primary sclerosing cholangitis.

Genetic associations and immunopathogenesis of coeliac disease

Coeliac disease is the most common disorder with malabsorption of the small instestine, caused by the gluten fraction of cereals in genetically predisposed individuals. Gluten peptides are efficiently presented by coeliac disease-specific HLA-DQ2- and HLA-DQ8-positive antigen-presenting cells, and thus drive the antigen-presenting cells, predominantly in the connective tissue of the lamina propria. The studying of the recently explored autoantibodies against tissue transglutaminase brought us further in the understanding of the pathophysiology of coeliac disease. The spreading of reliable serologic methods modified our knowledge on the clinical picture and prevalence of the disease. Long-standing untreated coeliac disease, even if clinically silent, predisposes for other autoimmune diseases. Therefore, population screening for immunoglobulin A antibodies to tissue transglutaminase seems justified.

Eradication of Helicobacter pylori has no effect on gastric acidity in duodenal ulcer patients--evaluation of 24-h pH monitoring

It is accepted that eradication of Helicobacter pylori leads to healing of chronic active gastritis facilitates ulcer healing and prevents ulcer recurrence in duodenal ulcer (DU) patients. However, it is not entirely known whether the eradication of the bacteria normalizes gastric acid secretion and abolishes dyspeptic symptoms after ulcer healing. This study was aimed to evaluate the intragastric acidity and dyspeptic complaints before, and 3 months after, eradication in 18 endoscopically proven H. pylori positive DU patients. Gastric pH was measured by 24-h continuous intraluminal recording, serum gastrin measurements and Congo-red tests were also performed. Dyspeptic complaints and antacid consumptions were recorded in diary cards, antisecretory therapy was not allowed after the cessation of eradication therapy. Endoscopy, H. pylori status and Congo-red tests were controlled at the 6th and 12th week, while pH measurements and serum gastrin tests were performed at inclusion and 3 months later. Three patients dropped out and in 14 out of the remaining subjects healing of DUs and successful eradication was achieved by the 6th and 12th week controls. The 24-h median pH and the percentage of 24-h pH readings under pH 3 were not changing significantly by the 3-month controls (from 1.9+/-0.5 to 1.8+/-0.4 and from 52.6+/-5.5% to 58.6+/-5%, respectively). Similarly, no significant changes were observed in serum gastrin levels and dyspeptic symptom scores (from 72+/-7 pg/ml to 56.7+/-8 pg/ml and from 2.69+/-0.4 to 1.26+/-0.3, respectively). The antacid consumption was almost stable when compared with the pre- and post-eradication periods. It was concluded that despite successful H. pylori eradication and healing of DU, intragastric acidity does not change significantly at least 3 months after the therapy. The persisting dyspeptic symptoms and the need for antacid consumption suggest that some healed ulcer patients require antisecretory therapy in the post-eradication period.

[Morphologic and clinical aspects of chronic gastric erosions]

Chronic erosions of the stomach are mostly papular lesions of the gastric mucosa with large base, 0.5-1 cm in diameter, often with superficial central depression covered with fibrin, less frequently without it. The typical site of lesion is the antrum the chronic erosions are here manifold, solitary forms are infrequent. In the course of 5694 gastroduodenoscopies the authors observed in 198 patients (5.2%) typical endoscopic picture of chronic erosions. In biopsy samples volcano-type lesions of the mucous membrane characteristic of the disease were found. According to the results the chronic erosions of the stomach are lesions of aspecific symptomatology, the disturbance of the mucosal barrier cannot be made probable. It is important to know the morphological characteristics of the rather frequent independent entity also for separating it from adenomas. Malignant transformation was not found in the material of the authors.

[Ph measurement in the stomach and duodenum through endoscopy]

The pH values were measured by means of a flexible glass-electrode through endoscope in the stomach and duodenum. The measuring instrument and technique are described. The luminal and juxtamucosal pH values were determined. The latter indicates the pH value prevailing on the epithelial surface of the viscid mucous layer. The gradient between the two values expresses the hydrogen-ion neutralizing capacity of the viscid mucus on the surface of the mucosa. Quantitative data on the first protective line of the gastric and duodenal mucous membrane may be obtained by measuring it. The pH values at different points of the stomach and duodenum were determined through endoscope in 24 patients with duodenal ulcer and in 15 controls. No significant difference was found between the two groups concerning the gastric luminal pH values, however the luminal pH of the duodenal bulb was significantly lower in patients with duodenal ulcer than that of the controls. In patients with duodenal ulcer the juxtamucosal pH value was significantly lower at several points in the stomach and in the duodenum too as compared to the controls. This refers to the insufficient neutralizing capacity of the viscid mucous layer. The pH measurement performed through endoscope furnishes in a simple way valuable clinical data, it is furthermore the first quantitative method which can be used routine-like for the examination of the barrier function of the viscid mucous surface in the stomach and duodenum of man.