Endoscopic therapy for bile duct stones in a geriatric population.

During the 5 year period to May 1988, 137 consecutive patients (age range, 65-102 years; median 84 years) with a diagnosis of choledocholithiasis, were referred to The Middlesex Hospital Geriatric Department. Endoscopic sphincterotomy was successful in 96.2% of cases and immediate biliary drainage was achieved in all but one of these patients. Stones were cleared endoscopically in 73.3% and surgically in 4.7% of cases. Long-term stenting was employed in 14.3% of patients. The 30 day mortality after endoscopic or surgical treatment was 4.7% (six deaths), although death was probably unrelated to therapy in half the cases. Deaths were due to procedural cardiorespiratory arrest (1), pancreatitis (1), pneumonia (2) and cerebrovascular accident (2). Endoscopic treatment is effective even in a high-risk geriatric population. After sphincterotomy patients with intact gall bladders should be managed expectantly.

Value of profiling liver function in the elderly.

The value of measuring three routine tests of liver function was assessed prospectively in 523 geriatric patients. Abnormalities were found in 27% of patients and were clinically helpful in half of these cases. Profiling liver function, without clinical indication, revealed abnormal results in 17% of patients and was important in one-third of these (6% of total). The two most important diagnoses were unsuspected osteomalacia and gall stone disease.

Non-operative removal of bile duct stones by duodenoscopic sphincterotomy in the elderly.

Between January 1975 and December 1979, 71 patients over the age of 70 underwent attempted duodenoscopic sphincterotomy for stones in the common bile duct. Fifteen patients still had gall bladders in situ. Sphincterotomy was possible in 69 of the patients and in 65 of these duct clearance was achieved, giving an overall success rate of 92%. Failure to achieve sphincterotomy in two cases was due to substantial peripapillary diverticula. Duct clearance failed in four patients, mostly due to the size of the retained stones. The largest stone extracted was 24 mm diameter. There were no deaths but complications occurred in nine patients (13%); these were haemorrhage in four (requiring surgery in one), cholangitis in four (two of whom required surgical extraction of stones), and pancreatitis in one. The average duration of hospital stay in successful cases was 11 days (range three to 30). Clinical follow-up of 55 patients one to five years after sphincterotomy showed no evidence of stones or of stenosis of the sphincter. Duodenoscopic sphincterotomy is a major advance in the management of elderly patients with stones in the common bile duct.

Septicaemia in the elderly.

A retrospective study was made of 44 elderly patients with bacteraemia treated in the period 1974-1980. Positive blood cultures in 5 cases were considered clinically insignificant. Twenty-six of the remaining 39 patients were found to have a Gram-negative bacteraemia, mainly associated with urinary tract infection. Abnormalities of liver function were common but 5 jaundiced patients with Gram-negative infection were shown to have stones in the common bile duct. The value of blood cultures as a diagnostic aid in the non-specifically ill elderly patient is emphasized.

Non-surgical palliation of malignant oesophageal obstruction in the elderly.

Fourteen elderly patients with malignant oesophageal obstruction have undergone palliative intubation with a modified Celestin tube inserted under intravenous sedation using a fibreoptic endoscopic technique. Eleven patients surviving the two-week post-insertion period had a mean survival time of five months (range 1--20 months). In the majority, palliation was excellent, most patients being able to eat a virtually normal diet within 36 hours of the procedure. This technique has a much lower mortality and morbidity in the elderly than palliative surgery and allows for early mobilization and discharge. Earlier referral of suitable patients is necessary and the technique deserves wider application.

Gastro-intestinal bleeding--a major cause of iron deficiency in the elderly.

Iron deficiency of 10 g/dl haemoglobin or less was found in 18 (3.5%) of 511 patients admitted in one year to the Middlesex Hospital Geriatric Unit. Three patients were frail and not investigated. Gastro-intestinal lesions were demonstrated in all remaining 15 patients and specific therapy was instituted in 10 cases. Surgery was performed for colonic cancer at a resectable stage (Dukes B) in two cases. Patients with iron deficiency require adequate gastro-enterological investigation.

Cimetidine for peptic ulcer in patients with arthritis.

Patients taking anti-inflammatory drugs for arthritis are prone to dyspepsia, and management of peptic ulcer is difficult because surgery is poorly tolerated. In this open study cimetidine treatment was associated with ulcer healing in 17 out of 21 patients with arthritis even when anti-inflammatory treatment was continued. Remission was maintained for 1 year by continued cimetidine therapy.

Benign oesophageal stricture in the elderly--use of cimetidine and fibre-optic dilatation.

Peptic strictures of the oesophagus may occur rapidly in the elderly. Dilatation of benign oesophageal stricture using a fibre-optic endoscope provides effective and safe treatment. Forty-eight dilatations were performed on 19 patients without significant complications. Swallowing was improved in all patients. The use of cimetidine is described.

Gray-scale ultrasonography and endoscopic pancreatography in pancreatic diagnosis.

Ultrasonography and endoscopic retrograde cholangiopancreatography (ERCP) were performed in 216 patients with known or suspected pancreatic disease. Both techniques provided accurate information in all groups of patients (normals and those with recurrent acute pancreatitis, chronic pancreatitis, and cancer), and there were no complications. Ultrasound scans gave more information concerning pseudocysts and were more often abnormal than pancreatograms in patients with recurrent acute pancreatitis. It is concluded that the combination of ultrasonography and ERCP constitutes a comprehensive diagnostic approach to patients with upper abdominal problems. The roles of other diagnostic tests for the pancreas, such as computed tomography, isotope scanning, function tests, and angiography, are also discussed briefly.

Acute gastro-intestinal bleeding in the critically ill patient.

Endoscopic studies have shown that all critically ill patients are liable to a degree of stress ulceration. Diffuse erosions appear first in the fundus and then spread to the corpus and antrum within 48 h. Duodenal disease is particularly common in burns patients. Discrete ulceration occurs in most severely injured patients. Mucosal damage is probably initiated by ischaemia but only develops in the presence of acid. Although related to the severity of underlying illness, haemorrhage is unpredictable. Mortality is high and largely unaffected by treatment. Emphasis should therefore be made on prophylaxis. Improved intensive reducing intra-luminal acid by antacid or H2 receptor antagonists appears to be the most effective measure, but controlled studies are required.

Malignant schwannoma of the stomach in a patient with von Recklinghausen's disease.

A patient with von Recklinghausen's disease died with a malignant schwannoma of the stomach and was found at autopsy to have neurofibromatosis of the gastrointestinal tract, a plexiform neurofibroma of the myocardium and a phaechromocytoma. Malignancy of the gastrointestinal tract in von Recklinghausen's disease is rare, and this case highlights the difficulties in histological diagnosis of malignant nerve sheath tumours.