Diagnostic accuracy of forceps biopsy versus polypectomy for gastric polyps: a prospective multicentre study.

AIMS: To determine whether an adequate histological diagnosis of gastric polyps can be attained on the basis of forceps biopsy. PATIENTS AND METHODS: In a prospective multicentre study, 194 patients with 222 endoscopically removable gastric polyps (>or=5 mm) underwent forceps biopsy and complete polypectomy. Patients with fundic gland polyps and polyposis syndrome were not included. Specimens were evaluated by primary and reference pathologists, and the complication rate of gastric polypectomy was also determined. RESULTS: Of the 222 polyps, histological examination of the polypectomy specimens revealed tumour-like lesions in 77% (10% focal foveolar hyperplasia, 59% hyperplastic polyps, 4% inflammatory fibroid polyps, 4% other polyps) and neoplasia in 19% (10% tubular adenoma, 2% tubulovillous adenoma, 1% high grade intraepithelial neoplasia, 6% adenocarcinoma). When biopsy results were compared, complete agreement was found in 124 cases (55.8%) and, in an additional 77 cases (34.7%), the clinically important differentiation between tumour-like lesions and neoplasia was possible. However, relevant differences were found by the reference pathologist in six cases (2.7%), the most common reason being failure of biopsy to reveal foci of carcinoma in hyperplastic polyps. Bleeding was observed after polypectomy in 16 patients (7.2%), in 15 of whom it was managed conservatively. CONCLUSIONS: We recommend complete removal by an experienced endoscopist of all epithelial gastric polyps larger than 5 mm after thorough individualised risk-benefit analysis.

Gastric involvement in progressive systemic sclerosis: electrogastrographic and sonographic findings.

OBJECTIVE: To determine whether electrogastrography (EGG) can discern sonographically demonstrated motility disorders in patients with progressive systemic sclerosis (SSc) and to evaluate EGG as a possible diagnostic tool. DESIGN: Prospective study with control group and testing for reliability. SUBJECTS: 15 SSc patients [women aged 33-70 years (mean 53.3 years)] and 15 healthy volunteers. METHODS: Bipolar cutaneous EGG was recorded to obtain the following parameters: period dominant frequency (PDF), percentage of gastric dysrhythmia and normogastria (defined as 2-4/min), period dominant power (PDP) and its change after a standardized meal of 500 kcal (2093 kJ), and instability coefficients of dominant frequency and power (DFIC, DPIC). Simultaneously, real-time sonography was performed in the aortomesenteric plane (3.5-MHz curved-array probe). In 10 patients and 13 control subjects, the distance from the anterior wall of the gastric antrum to the abdominal skin was measured. RESULTS: Three patients (20%) showed hypomotility of the gastric antrum sonographically. The percentage of bradygastria was significantly lower in these patients, but the PDF, DFIC and DPIC values were not significantly different. The distance between the cutaneous electrodes and the antrum bore a greater relationship to the PDP values than did the sonographically demonstrated number of gastric contractions. CONCLUSIONS: Although cutaneous EGG can be performed in SSc patients without apparent derangement in frequency and stability of the signal, it offers no advantage over sonography in diagnosis and follow-up.

Esophageal achalasia: intrasphincteric injection of botulinum toxin A versus balloon dilation.

BACKGROUND AND STUDY AIMS: In patients with esophageal achalasia, pneumatic dilation is the treatment of choice, but it bears the risk of perforation in about 4% of cases. A new nonsurgical method, intrasphincteric injection of botulinum toxin A, has shown promising initial results, and we thus undertook this study to compare the long-term outcome of these two methods. PATIENTS AND METHODS: In a prospective randomized study, 24 patients with definitive esophageal achalasia were divided into two equal groups and underwent either balloon dilation or injection of botulinum toxin (20 U injected into each of the four quadrants in the lower esophageal sphincter). The outcome was assessed on the basis of a symptom score documented before treatment and at regular intervals for two and a half years thereafter. Complications associated with the two techniques were also documented. RESULTS: No relevant complication occurred in either of the treatment groups. Initially, dilation was successful in 10 of 12 patients (83%), and botulinum toxin injection in 9 of 12 patients (75%). The symptom scores showed no significant differences between the two groups before and one month after treatment. Over the two and a half year follow-up, however, all nine successfully treated patients in the botulinum toxin group experienced recurrence of symptoms, but only four of the ten patients (40%) in the dilation group. CONCLUSIONS: The two treatment methods initially had equal success rates, but in the long term the effect of the botulinum toxin injection was statistically significantly shorter than that of balloon dilation. As fewer risks are associated with the injection treatment, studies should be undertaken either to identify patient subgroups in whom botulinum toxin can be effective long-term or to test substances with longer-lasting effects.

Botulinum toxin injection as a diagnostic tool for verification of sphincter of Oddi dysfunction causing recurrent pancreatitis.

Sphincter of Oddi dyskinesia (SOD) is among the less frequent causes of acute recurrent pancreatitis. We report on a patient with frequent pain attacks accompanied by pancreatic enzyme elevation, in whom a transitory decrease of the SO pressure following endoscopic botulinus toxin injection was a diagnostic clue for SOD. The patient's symptoms resolved for 4 months, after which time recurrent symptoms paralleled the reoccurrence of the elevated SO pressure. Endoscopic sphincterotomy of the biliary sphincter relieved her symptoms for the subsequent follow-up period which is now 10 months.

High- and low-compliance balloon dilators in patients with achalasia: a randomized prospective comparative trial.

BACKGROUND: Pneumatic dilation is the most effective nonsurgical method for treatment of achalasia. The most serious complication of this procedure is esophageal perforation, which occurs in about 5% of cases. We completed a randomized prospective comparative trial with a high-compliance latex balloon (HCB) mounted on an endoscope (40 mm maximum distension diameter, 6 psi inflation pressure) and a low-compliance balloon (LCB) (35 mm, 20 psi) with respect to efficacy and side effects. METHODS: Twenty-five patients (13 treated with HCB, 12 treated with LCB) were included. The symptom score was assessed both before and after dilation, biannually, for up to 2 years, and complications were graded for severity. All dilations lasted for 3 minutes and were performed under direct endoscopic control. Patients were randomly assigned to the two different balloon types. RESULTS: One perforation was observed in the LCB group (not significant between HCB and LCB). Superficial mucosal tears appeared in 40% of all dilations. Initial dilation treatment was successful in 20 of 25 (80%) patients (10 of 13 HCB, 10 of 12 LCB). There were no significant differences in the median pretreatment and post-treatment symptom scores. Three patients required repeated dilations during the observation period. They were treated with the competing balloon system and showed no difference compared with the initial posttreatment symptom score. CONCLUSIONS: No significant difference could be demonstrated between the HCB and LCB system as far as the complication rate and the clinical outcome are concerned. In consequence, both systems appear equally effective, although the endoscope-mounted system (HCB) can be handled more easily.