Usefulness of colonoscopy with biopsy in the evaluation of patients with chronic diarrhea.

OBJECTIVE: Patients referred for chronic diarrhea frequently undergo endoscopic evaluation. There are limited data on the role for colonoscopy with biopsy and ileoscopy for patients with chronic diarrhea. METHODS: We reviewed the charts of 228 patients with chronic diarrhea evaluated by colonoscopy between November 1995 and March 1998. Chronic diarrhea was defined as loose, frequent bowel movements for a minimum of 4 wk. Patients were excluded if biopsies were not performed in normal colons, if they had undergone previous bowel surgery, a history of inflammatory bowel disease, HIV, or an inadequate colonoscopy. RESULTS: One hundred sixty-eight patients were included in the analysis, of whom 142 (85%) had ileoscopy. Colonoscopy and biopsy yielded a specific histological diagnosis in 52 (31%) patients. These included Crohn's disease (9), ulcerative colitis (7), lymphocytic colitis (10), collagenous colitis (3), ischemic colitis (3), infectious colitis (6), and miscellaneous diseases (14). Ileoscopy yielded significant findings in 3% of patients (four with Crohn's disease and one with infection). CONCLUSIONS: Colonoscopy and biopsy is useful in the investigation of patients with chronic diarrhea yielding a histological diagnosis in 31% of patients without a previous diagnosis. Ileoscopy complemented colonoscopy findings in a minority of patients with chronic diarrhea and was essential for a diagnosis in only two patients.

Endoscopic pancreatic duct stenting to treat pancreatic ascites.

BACKGROUND: Management of pancreatic ascites with conservative medical therapy or surgery has met with limited success. Decompression of the pancreatic ductal system through transpapillary stent placement, an alternative strategy, has been reported in only a handful of cases of pancreatic ascites. METHODS: We reviewed all cases from 1994 to 1997 in which patients with pancreatic ascites underwent an endoscopic retrograde pancreatogram documenting pancreatic duct disruption with subsequent placement of a transpapillary pancreatic duct stent. Clinical end points were resolution of ascites and need for surgery. RESULTS: There were 8 cases of pancreatic ascites in which a 5F or 7F transpapillary pancreatic duct stent was placed as the initial drainage procedure. Pancreatic ascites resolved in 7 of 8 patients (88%) within 6 weeks. Ascites resolved in the eighth patient, a poor candidate for surgery, following placement of a 5 mm expandable metallic pancreatic stent. No infections, alterations in ductal morphology, or other complications related to stent placement were noted. There was no recurrence of pancreatic ascites or duct disruption at a mean follow-up of 14 months. CONCLUSIONS: Our experience doubles the number of reported cases in which transpapillary pancreatic stent placement safely obviated the need for surgical intervention in the setting of pancreatic ascites. This therapeutic endoscopic intervention should be seriously considered in the initial management of patients with pancreatic ascites.

Endoscopic management of the acute variceal bleeding event.

An examination of the published literature with regard to background and endoscopic management. Methods that are reviewed include laser, polymer injection, sclerotherapy, ligation and novel new methods. Sclerotherapy is compared to other non-endoscopic management. Ligation and sclerotherapy are compared for effectiveness and complications. Information on endoscopic therapy of gastric varices is also reviewed.

Extensive small bowel varices as a cause of severe anemia in Klippel-Trenaunay-Weber syndrome.

Klippel-Trenaunay-Weber (KTW) syndrome is a rare syndrome characterized by hemangiomata, varicose veins, and both bony and soft tissue hemihypertrophy. Abdominal viscera affected by ipsilateral hemangiomata include colon, liver, spleen, jejunum, kidney, and liver. We report a case of this syndrome that presented with severe anemia and extensive jeujenal varices without any other significant digestive tract lesions.

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.

Helicobacter pylori: an update for primary care physicians.

It is now widely accepted that H. pylori plays an important role in gastritis and PUD, and that eradication leads to a marked decrease in ulcer recurrence. H. pylori alone is not sufficient to cause ulcer disease. There is a complex interaction with acid production and mucosal protection. Treatment that is directed only at reducing acid production heals ulcers and is safe, but is temporary at best and does not address the underlying etiology. Currently treatment for H. pylori can only be recommended for patients with PUD confirmed to have H. pylori infection (Table 1). As further studies are done and more understanding is gained, these recommendations may be expanded. More research is needed with prospective studies to determine if eradication reduces the risk of gastric cancer. More research is also needed on shorter courses of treatment with fewer side effects, on the effectiveness of immunization against H. pylori, and on other innovative forms of treatment.