Five risk factors identify patients with gastroesophageal intussusception.

HYPOTHESIS: Risk factors in patients with gastroesophageal intussusception who have noncardiac chest pain need to be identified and analyzed. DESIGN: Prospective consecutive series of 43 patients with gastroesophageal intussusception. SETTING: Outpatient gastrointestinal endoscopy suite for 42 patients; 1 patient sustained gastroesophageal intussusception during labor and delivery and underwent an emergency laparotomy. INTERVENTION: Upper gastrointestinal tract endoscopy under intravenous sedation with appropriate monitoring of vital signs and photographic documentation in most patients. RESULTS: Gastroesophageal intussusception was documented endoscopically in 42 of 43 patients and was found to occur equally in men and women. Five risk factors have been identified: eating disorders or alcohol abuse, sudden sustained exertion, small-bowel obstruction, acid bile peptic disease, and pregnancy. Fifteen (70%) of 22 men were younger than 35 years; precipitating factors included sustained athletic effort and binge eating and drinking episodes. Fifteen (70%) of the 21 women were older than 35 years and had binge eating, peptic disease, and complications of pregnancy as risk factors. CONCLUSIONS: Five risk factors identify patients with severe vomiting or retching who are most likely to develop gastroesophageal intussusception, the precursor of a Mallory-Weiss tear. Upper gastrointestinal tract endoscopy with photographic documentation is the most accurate method of diagnosis. For most patients, medical management can reverse the cause of the vomiting. If vomiting is caused by mechanical obstruction or massive hemorrhage, surgical intervention may be necessary.

Thoracoscopic vagotomy as a safe adjunct to remedial gastric surgery.

Patients who have had prior subdiaphragmatic dissection with an incomplete vagotomy or Nissen fundoplication present added challenges when they require vagotomy and gastric resection. In this setting, thoracoscopic vagotomy offers significant advantages. A second attempt at vagotomy in a previously dissected field can be prolonged and frustrating. In addition to these concerns, repeat dissection can also lead to failure to find the vagal trunks, perforation of the esophagus, hemorrhage, and/or splenic injury. In our experience, three patients requiring gastrectomy or resection of a marginal ulcer have undergone thoracoscopic vagotomy at the time of transabdominal gastric surgery. The thoracoscopic approach avoided either a thoracoabdominal incision or combined thoracic and abdominal incisions while allowing dissection of the vagal trunks to be performed in normal tissue planes. The minimally invasive approach afforded decreased postoperative pain and excellent clinical results. Thoracoscopic vagotomy offers a welcome alternative to re-exploration of a previously dissected distal esophagus in search of vagal trunks, especially when they have been missed at the time of the first operation. Further application of this approach is recommended.

Complete regression of villous adenomas of the colon using piroxicam, a nonsteroidal anti-inflammatory drug.

A 73-year old patient with a past history of rectal carcinoma was found to have two sessile villous adenomas of the cecum. Because he refused surgical resection, a course of nonsteroidal anti-inflammatory drug therapy using piroxicam was given, and the villous adenomas regressed within three months. The cecum has remained clear at one year.

Giant marginal ulcer.

Marginal ulcer is a well-known complication of gastroenterostomy. It occurs in 3% of patients post-Billroth II subtotal gastrectomy; it occurs in less than 1% if truncal vagotomy is included but in up to 30% of patients with gastroenterostomy without vagotomy. These ulcers occur at the anastomosis, but always on the jejunal side, and are known to develop complications of their own--e.g., intractable pain; hemorrhage, obstruction, perforation, and fistula formation. Prior to the advent of upper-GI endoscopy the main method of diagnosis was by history and upper GI series but the accuracy of the upper-Gi series was about 50% or less. Now that upper-GI endoscopy is available, the accuracy of diagnosis is 95% or better. Since truncal vagotomy has been widely adopted as an integral part of gastric surgery--e.g., antrectomy, hemigastrectomy, subtotal gastrectomy, and gastroenterostomy--the incidence of marginal ulcer has declined. The use of cimetidine, ranitidine, famotidine, omeprazole, sucralfate, and antacids has improved the medical management of duodenal ulcer to such a degree that in recent years there is much less need for surgical intervention and thus the incidence of marginal ulcer has declined even more. In addition, the H-2 blockers and omeprazole can be used in patients with marginal ulcer and achieve healing; therefore complications that so frequently required surgical intervention are much less frequent.(ABSTRACT TRUNCATED AT 250 WORDS)

A new method of recording endoscopic and operative findings in colorectal neoplasia.

A new method of recording 12 relevant facts concerning patients with colorectal neoplasia has provided a neoplastic profile for each patient. With this information recorded on an outline of the colon one can see at a glance the date, histology, and location of the initial lesion; the number and timing of both synchronous and metachronous lesions and their histology; the size, differentiation, and location of each lesion; plus a family tree. This method provides pertinent clinical facts in chronological order and characterizes each patient's neoplastic activity without the need to refer to operative notes and laboratory reports. With this method, it is easy to record and easy to interpret, and it has been extremely useful in the clinical assessment of patients with colorectal neoplasia and in arranging appropriate surveillance for these patients.

Delayed gastric emptying after Roux-en-Y due to four types of partial obstruction.

Partial obstruction was the cause of delayed gastric emptying in 12 patients after a Roux-en-Y gastrojejunostomy in a consecutive personal series of 42 patients between 1975 and 1989. Four types of obstruction were identified. Type I was due to a kinked loop of jejunum where it passed through the mesocolon. Type II had the anastomosis too high on the gastric pouch, type III was due to an obstructing marginal ulcer, and type IV had a pouchlike deformity develop in the upper jejunum at the anastomosis that gradually compressed the outflow tract. No patient had stenosis of the anastomosis. The upper gastrointestinal (GI) series plus nuclear studies of the liquid and solid phase gastric emptying provided evidence of the presence and degree of delayed gastric emptying but not the site or cause of the obstruction. Upper GI endoscopy provided precise evidence of the site of the partial obstruction, its anatomic nature, and the presence of a bezoar or marginal ulcer. Of the 42 patients, 4 had surgical correction, and in 6 patients the obstruction was relieved by endoscopic manipulation; all patients have been relieved of their symptoms. Partial obstruction was the only cause of delayed gastric emptying in this series, and contrary to recent reports, no patient required a total or near total gastrectomy.

The impact of colonoscopy on colorectal carcinoma.

In an eight-year, ongoing study of 120 patients, 39 with carcinomas and 81 with adenomas, no patient has produced a new carcinoma despite a high incidence of metachronous adenomas. Colonoscopy can identify early carcinomas that can be resected for cure. In addition, colonoscopy can identify the adenomatous polyps and with polypectectomy prevent the progression to carcinoma. Colonoscopy is more accurate than air contrast barium enema, provides a tissue diagnosis, and allows polypectomy. When applied according to risk factors known to be cost effective, colonoscopy leads to earlier diagnosis and thus improved long-term survival.

A second look at the neostigmine morphine test.

In a prospective five-year study of 65 consecutive patients with upper abdominal pain the Neostigmine Morphine Test (NMT) was applied as a screen for biliary, ampullary, and pancreatic disease. Three facts emerged from this study: 1) the amylase and lipase were overly sensitive, but not specific and had only a 10 per cent predictive value for ampullary obstruction; 2) the bilirubin, alkaline phosphatase, and serum glutamic oxaloacetic transaminase (SGOT) were positive in patients with ampullary obstruction if they were postcholecystectomy but not so in patients with an intact gallbladder, which may be explained by the third observation; 3) the gallbladder can compensate for partial ampullary obstruction by dilatation five to ten times and by its ability to absorb 90 per cent of the water content of the bile. The Neostigmine Morphine Test is not a reliable screen for ampullary obstruction and positive findings must be confirmed by other studies.

The management of complications of Foley feeding gastrostomies.

The recent modification of the Ponsky technique of percutaneous endoscopic gastrostomy places a Foley catheter in the stomach instead of a mushroom catheter. Experience with four patients with long term Foley feeding gastrostomies revealed two types of complications that occurred 23 times, a) the rupture of the balloon fourteen times allowing the catheter to slip out and b) distal migration of the balloon causing intestinal obstruction nine times. Since long term feeding gastrostomies using a Foley catheter will continue to be used and probably increase with the recent modifications of the PEG it is essential that physicians and emergency room personnel be informed of those two complications. If and when either rupture of the balloon or distal migration occur, the Foley should be replaced with a mushroom catheter. Once the gastrocutaneous fistula is mature, usually after 2 weeks, it is safe to insert a mushroom catheter, which is not subject to those complications.

Immediate endoscopic placement of long intestinal tube in partial obstruction of the small intestine.

A technique that allows for endoscopic placement of a long intestinal tube with an inflatable balloon well beyond the pylorus is described. This procedure has been successful in 24 patients; is well tolerated; removes air and fluid from the stomach, duodenum and upper part of the jejunum, and can be performed in less than 45 minutes. It uses equipment that is standard in all hospitals and can be performed by anyone experienced in performing endoscopy of the upper part of the gastrointestinal tract. It is safe, easy to perform and improves the efficacy of long tube decompression and, therefore, can be recommended in properly selected patients, with partial obstruction of the small intestine.

Endoscopic decompression in partial small bowel obstruction.

Upper gastrointestinal endoscopy has been applied successfully in the management of patients with small bowel obstruction. In one group of patients after gastrectomy with a Roux-Y limb obstructed at the level of the transverse mesocolon, the endoscope was manipulated into this segment, and the tip was deflected in four directions with release of the kink. Conventional wisdom depends heavily on the interpretation of the upper gastrointestinal series, which in all five patients in this report proved to be incorrect. It was only through the endoscopic examination that the anastomoses were found to be patent, and the kinked segment of jejunum, once identified, could be released by endoscopic manipulation. Two patients required repeat endoscopy, and at last follow-up, all patients were eating well with no recurrence of symptoms. In the second group of patients with distal small bowel obstruction who normally would be considered for Miller-Abbott tube management, it was possible to decompress the stomach, duodenum, and upper jejunum endoscopically with immediate clinical and radiographic improvement. In addition, it was also possible to place the Miller-Abbott tube into the small bowel at the same time and thus avoid the 2 to 3 days of delay in advancing the tube beyond the pylorus. All patients had improvement and there were no complications. Although two required laparotomy several weeks later, they too were improved by the endoscopic procedures. The immediate decompression and rapid intubation represent significant advances in the management of patients with small bowel obstruction.

Spontaneous enterogastric reflux gastritis and esophagitis.

Enterogastric reflux gastritis and esophagitis is best known after gastric resections and pyloroplasty but it also occurs spontaneously in the nonoperated patient. Forty-two patients are presented who meet the criteria for the diagnosis: constant burning epigastric pain, worse after meals, unrelieved by antacids and diet; endoscopic demonstration of a gastric bile pool; endoscopic biopsy proof of gastritis and esophagitis; and hypochlorhydria. Patients with mild and moderate stages of the disease can benefit from metoclopramide therapy which improves the gastric emptying mechanism. Of the surgical patients with intractable symptoms, 90% were women, 90% had marked hypochlorhydria, 83% had biliary disease, current or remote, and 50% had anemia. With vagotomy, antrectomy, and Roux-Y anastomosis 45-60 cm downstream, the clinical response has been most encouraging.

Endoscopic retrograde cholangiopancreatography in the diagnosis of cystic duct syndrome.

The use of ERCP to identify cystic duct syndrome is reported for the first time herein. Nine patients with obscure biliary colic were further investigated with fat meal or CCK, cholecystogram or ERCP, or both, to identify the partial obstruction in the cystic duct. Cholecystectomy is curative in this disease. Because about one-third of the patients with disease of the gastrointestinal or biliary tracts or pancreas have two of these diseases simultaneously, it is essential that a thorough evaluation both preoperatively and at operation be performed so that a single well designed operation can be performed. ERCP has been helpful in defining the nature and extent of this disease.

Endoscopic biopsy for improved accuracy in upper gastrointestinal tract diagnosis.

Esophagogastroduodenoscopy has become the most accurate diagnostic method for identifying lesions of the upper gastrointestinal (GI) tract. It permits thorough inspection and a direct biopsy yielding a tissue diagnosis of surface lesions from the upper part of the esophagus to the second portion of the duodenum. The surgeon responsible for patients with upper GI tract disease should perform the endoscopic examination to gain first-hand information on the nature, extent, and location of the patient's problem. The surgeon-endoscopist gains an extra advantage, since the size and proximity of a lesion to the cardia, pylorus, or ampulla will determine surgical options available for the patient's problem. In patients with upper GI tract hemorrhage, the surgeon can determine immediately whether the bleeding is due to esophageal varices, Mallory-Weiss tear, gastric erosions, or an ulcer or tumor of the esophagus, stomach, or duodenum.