A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy. National Polyp Study Work Group.

BACKGROUND: After patients have undergone colonoscopic polypectomy, it is uncertain whether colonoscopic examination or a barium enema is the better method of surveillance. METHODS: As part of the National Polyp Study, we offered colonoscopic examination and double-contrast barium enema for surveillance to patients with newly diagnosed adenomatous polyps. Although barium enema was performed first, the endoscopist did not know the results. RESULTS: A total of 973 patients underwent one or more colonoscopic examinations for surveillance. In the case of 580 of these patients, we performed 862 paired colonoscopic examinations and barium-enema examinations that met the requirements of the protocol. The findings on barium enema were positive in 222 (26 percent) of the paired examinations, including 139 of the 392 colonoscopic examinations in which one or more polyps were detected (rate of detection, 35 percent; 95 percent confidence interval, 31 to 40 percent). The proportion of examinations in which adenomatous polyps were detected by barium enema colonoscopy was significantly related to the size of the adenomas (P=0.009); the rate was 32 percent for colonoscopic examinations in which the largest adenomas detected were 0.5 cm or less, 53 percent for those in which the largest adenomas detected were 0.6 to 1.0 cm, and 48 percent for those in which the largest adenomas detected exceeded 1.0 cm. Among the 139 paired examinations with positive results on barium enema and negative results on colonoscopic examination in the same location, 19 additional polyps, 12 of which were adenomas, were detected on colonoscopic reexamination. CONCLUSIONS: In patients who have undergone colonoscopic polypectomy, colonoscopic examination is a more effective method of surveillance than double-contrast barium enema.

Gallstones in chronic spinal cord injury: is impaired gallbladder emptying a risk factor?

OBJECTIVE: To confirm that spinal cord injured persons are susceptible to gallstones and to evaluate the role of gallbladder stasis as a risk factor. STUDY DESIGN: Twenty-nine subjects with chronic spinal cord injury underwent fasting ultrasonography to determine the incidence of gallstones and to quantitate gallbladder emptying response to a 20g fat liquid meal. Gallbladder emptying fraction was compared to that of healthy subjects studied concurrently. RESULTS: Gallstones or sludge were found in 6 spinal cord injured men, a minimal prevalence of 21%. Four additional subjects had prior cholecystectomy for stones, giving a potential maximal prevalence of 30%. Four of the 6 subjects had gallstone risk factors of diabetes, obesity, and/or family history. Gallbladder stasis was not apparent in chronic spinal cord injured subjects. Only 5 subjects had poor gallbladder emptying, and 4 of them had diabetes and/or obesity. CONCLUSIONS: The study confirms an increased prevalence of gallstones after spinal cord injury. However, gallbladder stasis did not appear to be etiologic, and most gallstones were associated with conventional risk factors. The results do not support a general policy of gallstone screening or prophylactic therapy after spinal cord injury.

The role of gallbladder emptying in gallstone formation during diet-induced rapid weight loss.

Obese persons are at risk for cholesterol gallstones because their bile is saturated with cholesterol. The risk increases during rapid weight loss by means of certain very-low-calorie diets or gastric bypass surgery. Gallstone risk factors during rapid weight loss include increased bile cholesterol saturation index and gallbladder stasis. Obese subjects were randomized to one of two low-calorie liquid diets for rapid weight loss: a 520-kcal diet with less than 2 g fat/d, and a 900-kcal diet with 30 g fat/d (including one 10-g fat meal to stimulate maximal gallbladder emptying). Bile and blood lipids, saturation index, leukocyte 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase activity, and ultrasonographic gallbladder emptying were measured repeatedly during dietary treatment. Both diets produced comparable weight loss of 22%. Bile cholesterol saturation index increased during both diets (26%), but fell to 15% below prediet level after weight loss. Compared with subjects' maximal gallbladder emptying fraction of 66%, the 520-kcal diet provided poor gallbladder emptying (35%), whereas the 10-g fat meal of the 900-kcal diet provided maximal emptying. Gallstones developed in four of six 520-kcal subjects and none of seven 900-kcal subjects (P = .021), an unanticipated difference that resulted in premature study termination for ethical reasons. Blood lipids and HMG CoA reductase activity in mononuclear leukocytes fell at week 8 during both diets, but recovered while weight was still being lost. The findings suggest that gallstone risk during rapid weight loss may be reduced by maintenance of gallbladder emptying with a small amount of dietary fat. Ultimately, weight loss reduced bile cholesterol saturation and improved highdensity lipoprotein (HDL) levels.

A randomized blinded comparison of omeprazole and ranitidine in the treatment of chronic esophageal stricture secondary to acid peptic esophagitis.

BACKGROUND: Esophageal strictures due to gastroesophageal reflux disease are often resistant to medical therapy and require repeated dilation procedures. Our aim was to compare the efficacy of therapy with omeprazole (20 mg/day) to ranitidine (150 mg twice daily) in the treatment of chronic esophageal strictures. METHODS: Thirty-three patients with chronic esophageal stricture disease (mean length of prior treatment, 50.9 months) were entered into a randomized blinded trial. The majority (88%) of the patients had received multiple prior esophageal dilations (mean, 7.9 per patient). Endoscopy and barium esophagograms were performed initially and at the end of 10 months. Symptoms were considered every 2 months and dilations performed as needed. The patient groups were equivalent. RESULTS: One patient in each group was subsequently lost to follow-up. No significant differences were seen in symptom improvement or need of dilation. At the final endoscopy, 8 of 17 (47%) patients receiving ranitidine had residual erosions or ulceration, compared with 1 of 14 (7%) patients receiving omeprazole (p >0.2). All patients receiving ranitidine had persistent strictures, whereas 8 of 14 (57.1%) patients receiving omeprazole had radiographic and endoscopic resolution of their strictures (p <0.004). CONCLUSION: These data further emphasize the need for vigorously treating esophagitis in patients with acid peptic strictures.

Variability in measurement of abdominal aortic aneurysms. Abdominal Aortic Aneurysm Detection and Management Veterans Administration Cooperative Study Group.

PURPOSE: The purpose of this study was to report interobserver and intraobserver variability of computed tomography (CT) measurements of abdominal aortic aneurysm (AAA) diameter and agreement between CT and ultrasonography observed in the course of a large, multicenter, randomized trial on the management of small AAAs. METHODS: CT measurements of AAA diameter from participating centers were compared with measurements made from the same scan by a central laboratory. Blinded central remeasurement of a randomly selected subset of these CT scans was used to assess intraobserver variability. Agreement between AAA measurements by CT and ultrasonography done within 30 days of each other was also assessed. RESULTS: For interobserver pairs of local and central CT measurements of AAA diameter (n = 806), the difference was 0.2 cm or less in 65% of pairs, but 17% differed by at least 0.5 cm. For intraobserver pairs of central CT remeasurements (n = 70), 90% differed by 0.2 cm or less, 70% were within 0.1 cm, and only one differed by 0.5 cm. Of 258 ultrasound-measured and central CT pairs, the difference was 0.2 cm or less in 44% and at least 0.5 cm in 33%. Ultrasound measurements were smaller than central CT measurements by an average of 0.27 cm (p < 0.0001). Local CT and ultrasound measurements showed a marked preference for recording by half centimeter. CONCLUSIONS: A high degree of precision is possible in CT measurement of AAA diameter, but this precision may not be obtained in practice because of differences in measurement techniques. Differences between imaging modalities increase variability further. Variations in AAA measurement of 0.5 cm or more are not uncommon, and this should be taken into account in management decisions. Efforts to reduce variation in measurement are warranted and might include (1) seeking agreement between surgeons and radiologists on a precise definition of AAA diameter, (2) limiting the number of radiologists who measure AAAs, and (3) use of calipers and magnifying glass for CT measurements.

Gallbladder emptying stimuli in obese and normal-weight subjects.

Gallbladder stasis may be an important factor in the pathogenesis of cholesterol-gallstone formation in some individuals. We investigated gallbladder function in a group of nondieting, gallstone-free, healthy subjects with normal (22 +/- 1 kg/m2) and high (36 +/- 1 kg/m2) body mass indexes. Fasting gallbladder volume (28.2 +/- 4.4 ml) and residual volume after maximal emptying (8.4 +/- 2.3 ml) in high-body-mass index subjects were not significantly different from those of normal-body-mass index subjects (20.5 +/- 2.5 ml and 4.2 +/- 1.3 ml, respectively). The percentage of gallbladder emptying (71% +/- 5%) and the rate of gallbladder emptying (-1.9 +/- 0.3 x 10(-2) min-1) in high-body-mass index subjects in response to a maximal emptying stimulus was similar to the percentage of emptying (78% +/- 6%) and rate of emptying (-2.3 +/- 0.6 x 10(-2) min-1) in normal-body-mass index subjects. A liquid meal containing less than 1 gm fat, 14 gm protein and 6 gm carbohydrate resulted in both a decreased rate of gallbladder emptying and an increased residual gallbladder emptying and an increased residual gallbladder volume in both groups. The addition of 10 or 20 gm (but not 4 gm) of fat to the liquid meal restored gallbladder emptying to the maximal-stimulus level. These results demonstrate that gallbladder emptying in response to a single liquid meal stimulus is not altered in obesity and that dose-response relationships to fat are similar in obese and normal-weight individuals.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiotherapy verification film for estimating cumulative entrance skin exposure for fluoroscopic examinations.

Measurement of skin entrance exposures during fluoroscopic procedures is complicated by the use of automatic exposure control devices and the presence of contrast media. Due to variability in positioning spot films from patient to patient, standard dosimeters, such as thermoluminescent, cannot be properly placed on the skin prior to examination. Prepackaged film of the type used for portal verification in radiation therapy held next to the patient's skin in a specially modified patient examination gown was found to be useful for determining the entrance skin exposure from both fluoroscopy and spot films during air contrast barium enema exams. The usable sensitivity range of this film has been found satisfactory for exposure measurements at exposures and kVps typically used for gastrointestinal fluoroscopic procedures. Errors in exposure estimates due to changes in film speed and contrast with kVp are less than 5% for the range of kVps used. Errors from variations in beam quality due to the adjacency of scattering material are approximately 5%. Entrance exposures determined with film agreed with those determined from TLD measurements to within 21%, with an average difference of 9%.

Pancreatic pseudocysts: clinical and endoscopic experience.

Records of 51 patients with proven pancreatic pseudocyst (PC) were retrospectively reviewed to assess clinical and endoscopic variables. Thirty-nine had surgery after preoperative endoscopic retrograde cholangiopancreatography (ERCP), six patients had ERCP only, and six patients had surgery without prior ERCP. Forty-two pancreatograms were obtained, and all were abnormal. PC communication with the pancreatic duct was present in 29 and ductal obstruction downstream from the PC was shown in 11 studies. Thirty-five cholangiograms were obtained and 19 were abnormal, including ductal narrowing in 16 and biliary calculi in three. PC contents were cultured intraoperatively in 29 patients, and 17 were positive. PC infection was highly correlated with the incidence of recurrent hospitalizations and with PC recurrence. PC infection did not occur significantly more often in patients with communicating PC or in those with preoperative ERCP. Factors that did not influence outcome included PC size, multiplicity, anatomic location, and PC communication with the pancreatic duct. Results from both ERCP and culture of PC contents add significantly to our knowledge of PC disease.

Efficacy of chenodeoxycholic acid and ursodeoxycholic acid for lowering cholesterol saturation index of gallbladder in patients with a sphincterotomy.

After endoscopic retrograde sphincterotomy, patients with an intact gallbladder are at risk for developing symptoms or complications of gallbladder stones. Medical dissolution of such stones would be desirable, especially in elderly patients with an increased surgical risk. However, sphincterotomy alters emptying dynamics of the gallbladder and markedly reduces bile salt pool size, effects that may alter response to chenodeoxycholic acid or ursodeoxycholic acid treatment. Studying two groups of 5 patients with an intact gallbladder after endoscopic retrograde sphincterotomy, we found that 15 mg/kg.day of chenodeoxycholic acid increased the mean (+/- SEM) biliary percentage of chenodeoxycholic acid from 35.5% +/- 4.0% to 88.8% +/- 1.9% (p less than 0.01) and decreased the mean saturation index of gallbladder bile from 1.02 +/- 0.22 to 0.55 +/- 0.08 (p less than 0.05). Ursodeoxycholic acid (10 mg/kg.day) increased the mean biliary percentage of ursodeoxycholic acid from 5.6% +/- 1.5% to 44.7% +/- 5.8% (p less than 0.01) and decreased the mean saturation index of gallbladder bile from 1.04 +/- 0.25 to 0.57 +/- 0.03 (p less than 0.05). A long-term trial of bile acid treatment in sphincterotomy patients with stones in an intact gallbladder is needed.

Partial biliary obstruction caused by chronic pancreatitis. An appraisal of indications for surgical biliary drainage.

This paper presents a retrospective review of 38 patients with intrapancreatic bile duct strictures secondary to chronic alcoholic pancreatitis. The strictures were identified by endoscopic retrograde cholangiopancreatography (ERCP). All patients with pancreatic cancer and gallstone pancreatitis were excluded. The mean alkaline phosphatase and total bilirubin values were 344 +/- 57 IU/dl and 4.4 +/- 0.7 mg/dl, respectively. The mean stricture length was 3.9 +/- 0.5 cm, and the mean common bile duct (CBD) diameter was 1.8 +/- 0.2 cm. The degree of bilirubin and alkaline phosphatase elevation did not correlate with stricture length or the severity of bile duct dilatation. Eighteen of the 38 patients received surgical biliary drainage (BD) as part of their initial therapy, and 20 patients did not. Liver function tests, intrapancreatic stricture length, and the degree of proximal CBD dilation were comparable in these two groups. Patients not undergoing BD did well clinically as only one patient required BD over an average follow-up period of 3.8 years. In conclusion, bypass of these strictures is usually unnecessary, and most patients may be safely treated without operation.

Preoperative endoscopic retrograde cholangiopancreatography in the surgical management of pancreatic pseudocysts.

Preoperative ERCP was performed on 39 patients treated surgically for pancreatic pseudocysts from 1970 to 1982 at the Minneapolis Veterans Administration Medical Center. ERCP-related sepsis was rare (4 percent of patients) and only occurred when surgery was delayed for more than 24 hours. The primary benefit of preoperative ERCP was to provide detailed information on pancreatic and biliary ductal anatomic characteristics other than those specifically related to the pancreatic pseudocyst. These data influenced the choice of operation in 49 percent of the patients. Specific preoperative surgical planning was facilitated and intraoperative pancreatography and cholangiography were obviated. Major postoperative complications occurred in 21 percent of the patients (0 percent mortality) but none were considered to be related to preoperative ERCP. ERCP before operation is a safe and important adjunct to surgical management of pancreatic pseudocysts. We strongly believe, however, that the interval from ERCP to surgery should not exceed 24 hours.

Clinical and endoscopic findings in patients early in the course of clostridium difficile-associated pseudomembranous colitis.

Endoscopic and clinical features are reported for 39 patients detected early in the course of pseudomembranous colitis. Disease was detected early by virtue of careful surveillance in patients in whom diarrhea developed. Early proctosigmoidoscopic findings in pseudomembranous colitis are illustrated. Clinical presentation includes development of fever, leukocytosis, abdominal pain, and even an ileus picture on radiography in addition to diarrhea.

Postsplenectomy gastric deformity.

Mass- or polyplike defects of the gastric fundus were found on upper gastrointestinal examination in five patients, representing 7% of those who had undergone splenectomy. In four cases, the splenectomies were performed 1--5 months earlier, and, in one, the splenectomy was performed 10 years before. Dense adhesions were the cause of the defects in two patients. Plication deformity was thought to be a possible cause in the others. Recognition of the nonneoplastic nature of such defects is important in preventing unnecessary surgery. Computed tomography and endoscopy may be helpful in confirming the diagnosis.

Is intravenous cholangiography still useful?

A retrospective study was performed to determine the usefulness of the intravenous cholangiogram for evaluation of common bile duct disease. Using interpretations obtained by chart review, 128 intravenous cholangiograms were categorized according to common bile duct visualization. Fifty-five percent of the studies were considered technically adequate for interpretation, while 23% and 22% were suboptimal and nondiagnostic, respectively. The intravenous cholangiogram diagnoses were verified when possible by comparison with the findings of: (a) endoscopic retrograde cholangiography, (b) operative cholangiography, (c) choledochotomy, or (d) autopsy. In verified studies of adequate intravenous cholangiograms, the diagnostic error rate was 40%, largely owing to missed stones. We conclude that the intravenous cholangiogram is usually unreliable for biliary tract evaluation, and should be replaced by alternative studies such as endoscopic or transhepatic cholangiography.

Simultaneous ulcerative colitis and Crohn's disease. Report of a case.

This report describes a patient with simultaneous Crohn's disease of the terminal ileum and ulcerative colitis of the left colon and rectum. Well documented cases of "mixed" ileocolitis are quite rare.

A comparison of upper gastrointestinal endoscopy and radiography.

One hundred symptomatic patients were evaluated independently with upper gastrointestinal radiography and fiberoptic endoscopy, and the results were compared. Of the two endoscopists sequentially examining the same patient, one was informed of available clinical and radiographic details and the other was not. Knowledge of the x-ray examination by the informed endoscopist did not improve his accuracy. Each endoscopist made four errors of interpretation. The endoscopic and x-ray findings agreed in 46 of the 100 patients, most often (68%) in esophagus, least often (29%) in the stomach and half the time (45%) in the duodenum. Ulcer craters seen endoscopically were detected radiographically in 36% of patients. We conclude that: 1) knowledge of results of prior upper gastrointestinal radiography did not alter endoscopic results; 2) experienced endoscopists are accurate but make mistakes; and 3) endoscopic findings would have been unaltered had radiography not been performed.