[Migration in two directions]

Percutaneous endoscopic gastrostomy [PEG], the modality of choice for long-term enteral access, is generally a safe procedure but can be associated with many potential complications. Report two different and late complications of PEG in two patients fed at home, leading them to the emergency department. A 75-year-old man and a 14-year-old young man with PEG presented to the emergency department with two different complications related to the gastrostomy tube. The first patient developed fever and deterioration in mental status due to parietal abscess which developed secondary to the migration of the internal button of the gastrostomy tube in the abdominal wall. He was treated with antibiotics and the gastrostomy tube was extracted. The second one presented upper gastrointestinal bleeding due to intestinal perforation at the level of the internal button of the gastrostomy tube. Bleeding and perforation were treated conservatively and he had a good evolution. Persons taking care of patients with PEG tube must be aware of potential complications. The position and the permeability of the tube must be systematically checked before feeding and medical advice should immediately be asked for in case of doubt or in the presence of any alarming sign

Treatment of achalasia by pneumatic dilatation [PD]: Local experience in treating 41 patients

L'achalasia is the best known primary motor disorder of the esophagus in which the lower esophageal sphincter [LES] has abnormally high resting pressure and incomplete relaxation with swallowing. Pneumatic dilatation [PD] remains the first choice of treatment. Our aim was to report, in a retrospective way, our experience in treating with pneumatic dilatation 41 achalasia patients admitted to the gastroenterology unit at Hotel-Dieu de France [HDF] hospital between 1994 and 2004. A total of 46 dilatations were performed in 41 patients with achalasia [20 males and 21 females, the mean age was 46.8 years [range, 15-90]]. All patients underwent an initial dilatation by inflating a 35 mm balloon to 7 psi three times successively under fluoroscopic control. The need for subsequent dilatation with the same technique or for surgical treatment was based on symptom assessment. The mean follow-up period was 36.7 months [3 mo-7 years]. Among the patients whose follow-up information was available, a satisfactory result was achieved in 29 patients [805%] after only one or two sessions of pneumatic dilatation. Esophageal perforation as a short-term complication was observed in one patient [2.17%]. Seven patients were referred for surgery [one for esophageal perforation and six for persistent or recurrent symptoms]. In conclusion, performing balloon dilatation under fluoroscopic observation is simple, safe and efficacious for treating patients with achalasia. Referral to repeated PD or to surgical myotomy should be discussed in case of no response to a first session of PD

Rectal dieulafoy's lesion report of two cases treated successfully by endoscopic means

Rectal Dieulafoy's lesion is an unusual cause of abrupt and massive lower gastrointestinal hemorrhage. It is characterized histologically by a caliber-persistent submucosal artery that protrudes through a minute mucosal defect. Various theories and risk factors have been proposed to explain the occurrence of bleeding but none is completely satisfying. We present two cases of rectal Dieulafoy's lesion which were treated efficaciously by a simple injection of a sclerosing agent in the first case and by a combination of epinephrine injection and thermal probe coagulation in the second leading to a complete and rapid disappearance of the abnormal vessel

Endoscopic resection of large pedunculated colonic polyps using endoloop three case reports and review of the literature

Endoscopic polypectomy is now an established procedure for the resection of colorectal polyps. One of the serious complications associated with colonoscopic polypectomy is hemorrhage. Several factors appear to be associated with increased risk of hemorrhage including patient age and colorectal polyp size, location, and morphology [thick stalk or sessile]. In particular, resection of large polyps is associated with a higher risk of serious complications. Bleeding most often occurs within the first 24 hours. More than 95% of cases of bleeding can be treated endoscopically by epinephrine injection, heater probe, or band ligation, alone or in combination. Several methods have been proposed for the prevention of hemorrhage after polypectomy. The most interesting approach is the use of a detachable snare [Endoloop] which allows endoscopic ligation of the stalk of a large, pedunculated polyp. In order to avoid the more severe consequences of bleeding, we use a detachable snare in two patients with a pedunculated polyp with a large head and stalk [> 2 cm]. In a third patient receiving anticoagulant, a detachable snare was chosen to safely and completely remove a large pedunculated polyp > 1.5 cm. In conclusion, colonoscopic polypectomy with Endoloop is safer than conventional polypectomy alone for resection of large, pedunculated polyps, especially in patients with liver disease, coagulopathy and receiving anticoagulant

Factors predictive of clinical outcome in upper gastrointestinal bleeding

Upper gastrointestinal bleeding [UGIB] is a frequent life-threatening emergency resulting in a large number of hospital admissions. Upper endoscopy has a crucial role in the diagnosis and treatment of UGIB, however the characteristics of our patients and the impact of our practice in these cases are still limited. Our aim was to assess, in a prospective way, the predictive factors of mortality in patients admitted to the gastroenterology unit at Hotel-Dieu de France hospital during the years 2002-2003 and to establish predictive factors of prolongation of hospital stay and occurrence of complications. Our study included 96 consecutive patients. The sex ratio was equal to 1 with a mean age of 63.24 +/- 8.72 years. Most endoscopic exams[67.7%] were done after 24 hours of the onset of UGIB. Endoscopic accuracy was a high as 98.95% [95/96 cases] with the use of 2 endoscopic exams to localize the bleeding lesion in only 4 cases [4.2%]. Peptic ulcer was the main cause of UGIB [44.8%], followed by bleeding erosive gastritis or duodenitis [13.5%], variceal bleeding [10.4%], oesophagitis [10.4%], and Dieulafoy's lesions[6.3%]. Endoscopic treatment was performed in 33.3% of the patients. Permanent hemostasis was achieved in 81.3% of the patients. Permanent hemostasis was achieved in 81.3% of the patients at the first endoscopic intervention and in62.5% of the patients at the first endoscopic intervention and in 62.5% of the patients after rebleeding. Rebleeding and/or absence of hemostasis after endoscopic diagnosis were reported in 15.6% of patients. Emergency surgery was rarely necessary [6 cases]. The average number of blood units was 3.37 +/- 2.28 per patient. Coagulation disorders, chemotherapy treatment, shock at admission and absence of hemostasis were predictive of a transfusion higher than 2 blood units on multivariate analysis. The average length of hospital stay was 9.58 +/- 5.97 days. The overall mortality rate of 10.4% was correlated, on the basis of multivariate analysis to 1/ cirrhosis, 2/ creatinin level higher than 110 micro mil/l, 3/ hemoglobin level at admission lower than 5 g/dl, 4/ prothrombin time below 60% and 5/ defective hemostasis after endoscopic intervention. In conclusion, when UGIB occurs in cirrhotic or renal insufficient patients or in the presence of coagulation disorders and when it is massive and uncontrollable it will be associated with a bad prognosis. In these cases a more aggressive treatment may be able to improve their outcome

Cirrhosis and renal insufficiency influence of the value of creatinine on prognosis

Renal failure in cirrhosis has multiple etiologies and numerous aggravating factors with evidence of worsening of prognosis. Our study was performed on 130 cirrhotic patients hospitalized in HDF between January 1st, 1994, and December 31st, 1999. We have evaluated the causes of renal failure and the relation of different aggravating factors with the onset of renal failure. Causes of renal failure included drug-induced renal failure, organic nephropathy, pre-renal azotemia, acute tubular necrosis and hepato-renal syndrome. Among the aggravating factors, lactulose was found to alter renal function [p = 0.0175]. We studied the survival with respect to the serum creatinine levels and to the severity of liver disease. Three-year survival was respectively 59% and 42% in case of Child A and Child B patients with creatinine lower than 90 micro mol/L. No three-year survivors were noted in these subsets of patients when creatinine level was higher than 90 micro mol/L [p = 0.0247 and p = 0.0121 respectively]. No difference in survival was noted in Child C cirrhosis The occurrence of renal failure is a factor of bad prognosis in cirrhotic patients irrespective of Child's classification. In patients with Child A and Child B cirrhosis, a serum creatinine level higher than 90 micro mol/L is a bad prognostic factor with a significantly decreased survival rate. This factor does not affect survival in Child C cirrhosis because of mortality related to cirrhosis complications

Traitement endoscopique des lesions de Dieulafoy

Dieulafoy's lesion is a rare and important cause of gastrointestinal hemorrhage. It is a relatively large artery which lies in close proximity to the mucosal surface. Hemorrhage is often torrential and life threatening. Endoscopy is the most sensitive diagnostic test. Many reports described successful hemostasis utilizing a variety of endoscopic modalities in > 95% of cases. We report an upper gastrointestinal hemorrhage in a patient with Dieulafoy lesion treated successfully by injection, and a literature review

Interest of endoscopic biopsy in the management of gastritis: about 250 consecutive cases

Background The practical role of gastric biopsy in the management of gastritis is controversial. Aim To estimate the yield of endoscopic biopsies in the clinical, endoscopic and pathologic approach of gastritis. Material and methods: Prospective study of 250 consecutive patients who underwent an upper G.I. endoscopy between July 1996 and January 1997, for upper G I symptoms, miscellaneous manifestations requiring an upper G.I. endoscopy or presenting a gastritis on EGD performed for other indications. Every patient had 6 biopsies: 2 in the antrum, 2 in the corpus, and 2 in an intermediate zone. Results After defining the abnormal elemental endoscopic and pathologic patterns, gastric mucosa was endoscopically normal in 57 cases [22.8%] and abnormal in the remaining of the 250 cases [77.2%]. The pathologic findings were normal in 69 cases [27.6%] and abnormal in the remaining 181 cases of 250. H pylori was found in 126 cases [50.4%], 10 cases of which [7.9%] had normal pathology. There was no significant correlation between clinical symptoms, endoscopy and pathology. There was a correlation between endoscopic abnormalities and tobacco use [P = 0.0073], NSAIDs use [P 0,0001] and the presence of H. pylori [P < 0,0001]. There was also a correlation between pathologic findings, tobacco use [P = 0.0015], NSAIDs use [P = 0.0022] and the presence of HP [P < 0.0001] On the other hand, there was a correlation between the presence of an inflammatory infiltrate in H. pylori gastritis [P 0.0007] and its absence in NSAIDs use [P = 0.0003]. The correlation between endoscopy and pathology existed only for certains patterns: erosion and ulcerations [P = 0.0002], purpuric [P = 0.033], congestion [P < 0.0001] and mosaic [0.0095]. Conclusion: Gastric biopsy brings no important practical supplement to endoscopic examination except in revealing the presence of H. pylori. It adds nothing to endoscopy in helping explain the clinical symptoms. But it is obvious that it may reveal some serious pre-malignant dysplasia or malignant gastric lesions [maltoma, linitis plastica]. This did not occur during our study

La famotidine dans le traitement de l'ulcere gastrique

In order to evaluate the efficacy and tolerance of Famotidine in the treatment of gastric ulcer, in Lebanese patients, we conducted a prospective open study in twenty one patients with benign gastric ulcer. A clinical, endoscopic and biological evaluation was done before, at 4 weeks and if necessary at 8 weeks after the start of 40 mg of Famotidine per day. All patients were carefully monitored at regular intervals for adverse drug reactions by clinical and biological examinations. The healing rate at 4 and 8 weeks was 75% and 91% respectively. The treatment was well tolerated and no modifications in laboratory tests were observed. Famotidine therefore proved effective in the treatment of gastric ulcer and was well tolerated on a short term basis

problems therapeutiques poses par les syndrome de Gardner, a propos d'une famille Libanaise

Gardner's syndrome is an autosomal dominant disease characterised by the association of a polyposis coli with one or more of specific extracolonic manifestations. A Lebanese family is reported. Polyposis coli, desmoid tumors, gastroduodenal polyps, procreation counselling etc are difficult problems to manage in this syndrome