Peptic ulcer disease in pregnancy.

In general, peptic ulcer disease during pregnancy is relatively rare. Certainly, gastroesophageal reflux symptomatology and hyperemesis gravidarum are the primary pregnancy-associated upper gastrointestinal tract illnesses. The symptoms of dyspepsia accompanies all three diagnoses and makes it difficult to determine whether peptic ulcer is playing a role in the patient's symptomatology. Patients with a previous history of complicated peptic ulcer diatheses should be suspected of having recurrent ulcer disease and treated accordingly. Endoscopy is not to be feared if needed to confirm a diagnosis of peptic ulcer disease or to aid in the diagnosis of the patient with upper gastrointestinal tract hemorrhage. There is thought to be some improvement in peptic ulcer disease with pregnancy, which may be secondary to lower gastric acid output and increased protective mucus production associated with elevated progesterone levels. This may afford some level of protection against this disease process in pregnant women. Patients who are smokers and have a previous history of peptic ulcer disease are at highest risk for ulcer disease during pregnancy. Multiple agents have been found to be relatively safe and effective for ulcer healing, with H2 antagonists the mainstay of therapy during pregnancy.

Status evaluation: biliary stents. American Society for Gastrointestinal Endoscopy. Technology Assessment Committee.

Large caliber plastic stents (10 to 11.5 French) have become widely accepted as an alternative to surgery in the treatment of many malignant and benign lesions of the biliary tract. Procedure-related early complications occur at an acceptable rate (8 to 10%) and procedure-related mortality is approximately 2%. Late clogging occurs at a mean of 4 to 6 months. This results in the need to change a clogged stent in 20 to 35% of surviving patients with malignant disease. In benign or malignant disease, when long-term stenting is desired, it is generally recommended to prophylactically replace the stent every 4 to 6 months to avoid clogging. While several mechanisms of clogging have been elucidated, research studies have failed to lead to a clinically available improvement in duration of patency. The role of expandable metal stents in the treatment of malignant and benign biliary strictures has not been established. Despite their large internal diameter, they may be associated with late problems related to stent clogging from tumor ingrowth or overgrowth. Technical difficulties and expense, as well as lack of data from prospective randomized trials, limit current recommendation for their use at this time.

Status evaluation: sphincter of Oddi manometry. American Society for Gastrointestinal Endoscopy. Technology Assessment Committee.

SO manometry appears to be helpful in defining a group of patients with biliary pain or idiopathic recurrent pancreatitis who may benefit from endoscopic or surgical treatment. It is a procedure that requires considerable time and endoscopic expertise along with knowledge of the manometric interpretation of sphincter of Oddi dysfunction. The diagnostic accuracy of SO manometry and criteria for basing therapeutic decisions on manometric findings need further study and verification.

Status evaluation: hot biopsy forceps. American Society for Gastrointestinal Endoscopy. Technology Assessment Committee.

Monopolar hot biopsy forceps were developed for simultaneous tissue biopsy and electrocoagulation. Many endoscopists used these forceps for coagulation of diminutive polyps of the colon. The rationale for diminutive polyp eradication is to destroy neoplastic tissue and possibly prevent colon cancer. However, convincing data to document a reduction in the incidence of colorectal cancer or even complete obliteration of all treated diminutive polyps with hot biopsy forceps are lacking. Complications of hot biopsy include hemorrhage, perforation, and post-coagulation syndrome. Tissue injury is deeper with monopolar hot biopsy forceps than bipolar forceps. The right colon is particularly susceptible to transmural injury and perforation. For small polyp obliteration, comparative studies of hot biopsy (monopolar and bipolar) with other techniques such as cold biopsy combined with thermal probes, large cup cold biopsy removal, and snare electrocoagulation are warranted. The necessity to biopsy typical appearing angiomata does not seem warranted on a routine clinical basis. The expected obliteration rates of small angiomata or rates of controlling lower gastrointestinal bleeding from colon angiomata after monopolar hot biopsy electrocoagulation have not been well documented. Heater probe or bipolar electrocoagulation have been safely and effectively applied to bleeding colon angiomata. These newer coagulation probes are recommended as an alternative to hot biopsy forceps for treatment of bleeding colonic angiomata.

Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices.

BACKGROUND: Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques. METHODS: In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival. RESULTS: Active bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12 of 14 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication of varices required a lower mean (+/- SD) number of treatments with ligation (4 +/- 2 vs. 5 +/- 2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041), as was the rate of complications (22 percent vs. 2 percent, P less than 0.001). The complications of sclerotherapy were predominantly esophageal strictures, pneumonias, and other infections. CONCLUSIONS: Patients with cirrhosis who have bleeding esophageal varices have fewer treatment-related complications and better survival rates when they are treated by esophageal ligation than when they are treated by sclerotherapy.