The effect of sedation on the quality of upper gastrointestinal endoscopy: an investigator-blinded, randomized study comparing propofol with midazolam.

BACKGROUND AND STUDY AIMS: Sedation with propofol is associated with a high acceptance rate in upper gastrointestinal endoscopy. So far, however, there are no valid data on whether the use of propofol can increase the general quality of the endoscopic examination. PATIENTS AND METHODS: A total of 60 patients referred for upper gastrointestinal endoscopy were randomized to receive sedation with either midazolam (n = 30) or propofol (n = 30). The maximum dosages permitted were 5 mg of midazolam and 500 mg of propofol. The examinations were recorded on videotapes, and the quality of upper endoscopy was assessed by videotape analysis by three experienced endoscopists who were all blinded to patient data and the medications used for sedation. A score sheet was used with 18 assessment items that each represented a step of upper gastrointestinal endoscopy and a global score for the entire examination. A scale ranging from 1 (excellent) to 6 (very poor) was used. Data were analyzed on an intention-to-investigate basis: inability to perform the procedure because of a patient's intolerance of the procedure, for example, was scored as 6 (i. e. very poor). RESULTS: Patients in the two groups were well matched with respect to demographic and clinical data. Four patients in the midazolam group could not be adequately examined. The median dosage used for sedation was 5 mg midazolam (range 2-5 mg) and 160 mg propofol (range 70-320 mg). When assessments by all three blinded examiners were added together, propofol sedation was found to result in significantly better scores for all parameters except for the assessments of "Z-line/cardia", "duodenal bulb", and "duodenal folds" (all P < 0.05, Mann-Whitney U test). CONCLUSION: Sedation with propofol might increase the quality of upper endoscopy. This finding may have a significant impact on the selection of the type of sedation, not only in terms of increasing patients' acceptance of the procedure, but also for improving the diagnostic accuracy of upper gastrointestinal endoscopy.

Argon plasma ablation of gastric inlet patches in the cervical esophagus may alleviate globus sensation: a pilot trial.

BACKGROUND AND STUDY AIMS: Globus sensation and/or sore throat have been associated with both gastroesophageal reflux disease and the presence of a gastric inlet patch. There have been no reports, however, on whether ablation of heterotopic mucosa in the cervical esophagus leads to improvement of chronic globus sensation. PATIENTS AND METHODS: Ten patients with a histologically proved gastric inlet patch who complained of chronic globus sensation and/or sore throat were included in this prospective pilot study. After a thorough assessment, including videofluoroscopy, laryngoscopy, manometry, and 24-hour two-channel pH monitoring, patients underwent argon plasma coagulation (APC) to ablate the heterotopic mucosa. A questionnaire with a visual analog scale ranging from 0 to 10 was used for assessment of globus sensation, sore throat, and other typical or atypical reflux symptoms. Follow-up examinations (including symptom assessment) were performed 4 weeks and 8 weeks after APC therapy. RESULTS: Ablation of the gastric inlet patch resulted in a significant reduction of median symptom scores for globus sensation (from 2.7 to 0) and sore throat (from 2.8 to 0) 8 weeks after therapy ( P < 0.05), but there was no improvement in other reflux-related symptoms. Acid reflux in the distal and proximal esophagus, determined by two-channel pH monitoring, did not change after therapy. CONCLUSIONS: Our preliminary data suggest that ablation of gastric inlet patches by APC can alleviate chronic globus sensation or sore throat. Acid reflux or its treatment is unlikely to influence these results. A randomized and blinded study is warranted.

Endoscopic ultrasound criteria for vascular invasion in the staging of cancer of the head of the pancreas: a blind reevaluation of videotapes.

BACKGROUND: It has been claimed in several prospective studies that endoscopic ultrasonography (EUS) is highly accurate in the locoregional staging of pancreatic cancer. However, the value of the EUS criteria for the diagnosis of vascular involvement is less well established. To totally exclude potential bias introduced by the availability of prior information, a completely blinded analysis of videotapes of patients with cancer of the pancreatic head was therefore conducted. METHODS: Videotape sequences of 75 patients with cancer of the head of the pancreas with surgical confirmation or unequivocally positive angiography demonstrating vascular invasion were reevaluated without any clinical data or information from other imaging studies. Involvement of the vascular system (portal vein with confluence, superior mesenteric vein, celiac axis) was assessed on EUS with special emphasis on EUS parameters of the tumor-vessel relationship. RESULTS: The overall sensitivity and specificity of EUS in the diagnosis of venous invasion were 43% and 91%, respectively, when using predetermined parameters (visualization of tumor in the lumen, complete obstruction, or collateral vessels). If the parameter "irregular tumor-vessel relationship" had been added to these criteria, the sensitivity would have risen to 62%, but the specificity would have fallen to 79%. The only vascular system that could be properly visualized by EUS was the portal vein/confluence area. The positive and negative predictive values for the single parameters chosen to diagnose portal venous involvement were as follows: 42% and 33% for irregular tumor-vessel relationship, 36% and 34% for visualization of tumor in the vascular lumen, 80% and 28% for complete vascular obstruction, and 88% and 18% for collateral vessels. CONCLUSIONS: In a completely blinded evaluation of the EUS diagnosis of vascular invasion by cancer of the head of the pancreas it was not possible to find suitable morphologic parameters with clinically useful sensitivity and specificity values (over 80%).

Endoscopic ultrasonographic study of the azygos vein before and after endoscopic obliteration of esophagogastric varices by injection sclerotherapy.

BACKGROUND AND STUDY AIMS: The azygos vein plays an important role as a drainage system for the superior portosystemic collateral circulation in portal hypertensive patients. Endoscopic ultrasonography (EUS) and Doppler EUS allow the performance of hemodynamic studies of the azygos vein. In this study, we observed the changes in the azygos vein which occur with variceal obliteration by endoscopic injection sclerotherapy (EIS). PATIENTS AND METHODS: We recruited patients with portal hypertension and bleeding varices who were not on portal pressure-lowering agents and who were scheduled for the EIS program. EUS was performed in these patients to study the azygos vein at the start of EIS. The azygos vein diameter, maximal velocity (Vmax), and blood flow volume index (BFVI) were measured. After variceal obliteration and within 1 week, another EUS study of the azygos vein was carried out. RESULTS: Out of 40 patients recruited into the study variceal obliteration and EUS assessment of the azygos vein, within 1 week of obliteration, was achieved in 33. We noticed a significant increase in azygos vein diameter (P<0.001) and BFVI (P=0.001) following variceal obliteration. No significant change was observed in Vmax (P>0.05). In one patient, marked caliber irregularities were observed in the azygos vein after variceal obliteration. CONCLUSIONS: Using EUS and Doppler EUS, hemodynamic studies of the azygos vein blood flow can be performed, allowing the monitoring of the effects of EIS and variceal obliteration on the superior portosystemic collateral circulation. The clinical significance of the observed changes in azygos blood flow that occur with variceal obliteration should be investigated in further studies and correlated with short-term and long-term outcome.

Microbiological examinations and in-vitro testing of different antibiotics in therapeutic endoscopy of the biliary system.

BACKGROUND AND STUDY AIMS: Prior to endoscopic therapeutic procedures, no antibiotic prophylaxis is administered routinely. Because of the reported incidence of infectious complications, which may reach up to 10%, a prospective study was undertaken to investigate the effects of a prophylactic dose of cefuroxime on the incidence of bacteremia and clinical signs of infection, but no significant effects could be demonstrated. In addition to this published work, blood and bile cultures obtained in this trial were also investigated, and the in-vitro susceptibility to several antibiotics was tested in order to recommend the appropriate substances. PATIENTS AND METHODS: Ninety-nine consecutive patients (51 men, 48 women; mean age 61.4 +/- 17 years) with biliary obstruction who underwent an endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography with drainage (PTCD) were included. Sequential blood cultures were taken before and up to 60 minutes after the endoscopic intervention. Bile cultures were obtained in 56 patients with biliary drainage. Aerobic and anaerobic cultures were prepared from all obtained specimens and the isolated organisms were identified. In the case of positive cultures, an in-vitro resistance test for 15 different antibiotics was performed. RESULTS: The incidence of bacteremia was 11.1% (n = 11), and 16 bacteria were isolated. Twelve different microorganisms were detected, with Escherichia coli found in four cases. From 41 positive out of 56 prepared bile cultures (73.2%), 91 isolates were found with 25 different species. A single agent was detected in eight cases (19.5%), while a mixed growth, with pathogens ranging from two to six species, was found in 33 cases (80.5%). The seven most frequently isolated germs were E. coli and Enterococcus (each n = 19), Klebsiella (n = 10), Streptococcus viridans (n = 9), Staphylococcus epidermidis (n = 5), Morganella morganii (n = 4), and Bacteroides fragilis (n = 3), representing 76% of all agents. Examination for fungal infection revealed positive cultures of Candida albicans in 16.1% of bile cultures (nine of 56). Interestingly, the use of proton-pump inhibitors (PPIs), with a consequent rise in the gastric pH value, led to an increase in the rate of bacteremia to 26.2% (five of 19) compared to the other patients not on PPIs (n = 80), who developed bacteremia in only six cases (7.5%; p = 0.02). In-vitro testing of different antibiotics was carried out in 73 isolates. Imipenem showed the best antimicrobial activity (98.4%), followed by trimethoprim and sulfamethoxazole (90%), amoxicillin plus clavulanic acid (87.3%), vancomycin (82.4%), and ofloxacin (76.9%). CONCLUSIONS: Escherichia coli was found to be the pathogen most frequently detected in blood and bile following endoscopic interventions in the biliary tract. Enterococci, Klebsiella and Streptococcus viridans were found in bile cultures with an incidence exceeding 10%. In view of the in-vitro test results, possible side effects, and contraindications, amoxicillin plus beta-lactamase inhibitors or quinolones are considered to be suitable antibiotics for the prophylaxis of biliary infections.

Endoscopic ultrasonographic study of the azygos vein in patients with varices.

BACKGROUND AND STUDY AIMS: Using EUS in the study of portal hypertensive patients, various divisions of the gastroesophageal collateral circulation can be demonstrated. The azygos vein, which is the main drainage system for varices, can also be scanned endosonographically. We studied the azygos vein in control subjects and portal hypertensive patients using EUS. PATIENTS AND METHODS: Our study included 17 patients with endoscopic evidence of esophagogastric varices and 11 control subjects not suffering from chronic liver disease or varices. EUS and Doppler EUS using a linear scanning echoendoscope were carried out on patients and control subjects with the aim of studying the azygos vein. RESULTS: The azygos vein could be scanned in all subjects and was found to be significantly dilated in patients with varices. Maximal velocity of its blood flow was higher among patients with varices compared to control subjects. Periazygos collaterals could be occasionally observed in portal hypertensive patients. CONCLUSION: EUS can be used both for scanning and hemodynamic studies of the azygos vein. The fact that EUS allows the collection of valuable quantitative and qualitative data from the azygos vein should encourage further studies on the clinical value of this information in the follow up of portal hypertensive patients.

Cumulative indices of DNA synthesizing myocytes in different compartments of the working myocardium and conductive system of the rat's heart muscle following extensive left ventricle infarction.

Ten successive 3H-thymidine injections at 12 h intervals (which is a little shorter than the adult heart myocyte S phase) were performed for labeling of the majority of cardiac myocytes synthesizing DNA at any moment of such a 5 days experiment. In the hearts of control unoperated rats ten-fold repeated 3H-thymidine administration results in labeling of 2-3% myocyte nuclei in both atria, ca. 1% of the specialized muscle cell nuclei in the atrioventricular conductive system, only occasional muscle cells being labeled in the working ventricular myocardium. When ten successive 3H-thymidine injections were made between the 5th and 10th days following extended left ventricle infarction, the percentage of labeled myocytes in left and right atria reaches, respectively, 51.4 +/- 4.4% and 34.7 +/- 3.6%. In the left ventricle labeled muscle nuclei are accumulated predominantly (9.3 +/- 2.1%) within the thin subepicardial layer of the surviving myofibers, while myofibers located in other perinecrotic areas contained only 1.3 +/- 0.5% labeled muscle nuclei. The number of these nuclei in the atrioventricular system remains at the level observed in control hearts (up to 2%), approaching closely the zero level in the working myocardium of both the ventricles and interventricular septum, located at the considerable distance from the infarcted region. When similar experiments with ten-fold repeated 3H-thymidine injections were performed between 15th and 20th post-infarction days the number of labeled myocyte nuclei was found to be reduced 4-6 times in atria, being changed rather a little in the perinecrotic ventricular myocardium and in the specialized myocardium of the atrioventricular system. Some possible reasons of the observed differences in the proliferative behaviour of cardiac myocytes in terms of their topology and/or specialization are discussed.