Age and alarm symptoms do not predict endoscopic findings among patients with dyspepsia: a multicentre database study.

INTRODUCTION: Symptoms of dyspepsia are common but most patients do not have major upper gastrointestinal pathology. Endoscopy is recommended for dyspeptic patients over the age of 45, or those with certain "alarm" symptoms. We have evaluated the effectiveness of age and "alarm" symptoms for predicting major endoscopic findings in six practising endoscopy centres. METHODS: Clinical variables of consecutive patients with dyspepsia symptoms undergoing upper endoscopy examinations were recorded using a common endoscopy database. Patients who had no previous upper endoscopy or barium radiography were included. Stepwise multivariate logistic regression was used to identify predictors of endoscopic findings. The accuracy of these for predicting endoscopic findings was evaluated with receiver operating characteristic analysis. The sensitivity and specificity of age thresholds from 30 to 70 years were evaluated. RESULTS: Major pathology (tumour, ulcer, or stricture) was found at endoscopy in 787/3815 (21%) patients with dyspepsia. Age, male sex, bleeding, and anaemia were found to be significant but weak independent predictors of endoscopic findings. A multivariate prediction rule based on these factors had poor predictive accuracy (c statistic=0.62). Using a simplified prediction rule of age > or =45 years or the presence of any "alarm" symptom, sensitivity was 87% and specificity was 26%. Increasing or decreasing the age cut off did not significantly improve the predictive accuracy. CONCLUSIONS: Age and the presence of "alarm" symptoms are not effective predictors of endoscopic findings among patients with dyspepsia. Better clinical prediction strategies are needed to identify patients with significant upper gastrointestinal pathology.

Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data.

BACKGROUND: Simple endoscopic retrograde cholangiopancreatography (ERCP) outcome measures such as success and complication rates may not allow direct comparisons among endoscopists or centers because procedure degree of difficulty can vary tremendously from case to case. We propose a new grading scale designed to objectively quantify ERCP degree of difficulty. METHODS: A 1 to 5 scale was devised to grade ERCPs according to their level of technical difficulty. A retrospective pilot study was performed to assess ERCP outcomes at our institution according to difficulty grade. The scale was then prospectively applied to all ERCPs during a 1-year period. RESULTS: In the pilot study, 209 of 231 (90%) ERCPs were technically successful, and 8 (3%) were followed by complications. Grade 1 to 4 procedures were more likely to succeed (94% vs. 74%, p< 0.05) and less likely to have associated complications (2% vs. 10%, p< 0.05) than grade 5/5B ERCPs. Of 187 ERCPs assessed prospectively, 166 (89%) were successful and 10 (5%) were followed by complications; 132 of 138 (96%) grade 1 to 4 procedures succeeded compared with 30 of 46 grade 5 to 5B ERCPs (65%, p<0.001), but complications were not significantly more frequent in grade 5 to 5B ERCPs (8.7% vs. 4.3%, p = not significant). CONCLUSIONS: Technical success was dependent on ERCP degree of difficulty, but complications were not. Outcome data that incorporate degree of difficulty information may be more meaningful, allowing endoscopist-to-endoscopist and center-to-center comparisons.

Successful endoscopic removal of a severed, impacted Dormia basket.

We report the successful removal of a severed and impacted Dormia basket from an elderly patient with choledocholithiasis. One aspect of the case that increased its difficulty is that the basket had become trapped in the bile duct by attaching to an immobile stone that had formed on suture material from a prior biliary operation. Severed baskets that become entrapped in the bile duct are unusual complications of endoscopic bile duct stone removal which used to require surgical intervention. More recent reports suggest that retained baskets can be removed endoscopically in conjunction with some form of lithotripsy. The method used to remove the retained basket in our case involved advancing a Soehendra lithotripter over a looped guidewire after first shrinking the stone with extracorporeal shock wave and laser lithotripsy.

Outcomes of patient disengagement policies: implications for managed care.

The gastroenterology division at Wilford Hall Medical Center (WHMC) refers approximately 70% of outpatient consultations to civilian providers, a policy known as disengagement. This policy was implemented in the hope of reducing waiting times for appointments and testing. We conducted a telephone survey to determine whether disengaged patients eventually obtained health care and, if they did not, the reasons for this. We also attempted to determine the level of patient satisfaction with this policy. The results demonstrated that many patients did not obtain care within the 6-month follow-up period, largely because of financial considerations. Most patients were also dissatisfied with the policy and disappointed at not having obtained care at WHMC. The results of this study have important implications for Tricare, which might result in impaired access to care through out-of-pocket patient expenses related to cost-shares and membership fees.

Adenosine nucleotides in bile.

Activation of purinergic receptors by ATP stimulates Cl- efflux in biliary epithelial cells. To determine whether purinergic agonists are present under physiological conditions, we have assayed mammalian bile for nucleotides and assessed whether hepatoma and cholangiocarcinoma cell lines are capable of nucleotide release. Bile samples were collected from human, rat, and pig donors and assayed for nucleotide concentrations by luminometry. ATP, ADP, and AMP were present in bile from each species, and the average total nucleotide concentration in human bile was 5.21 +/- 0.91 microM (n = 16). In an in vitro model of HTC rat hepatoma cells or Mz-ChA-1 cholangiocarcinoma cells on a superfused column, nucleotides were present in the effluent from each cell type. Addition of alpha, beta-methyleneadenosine 5'-diphosphate (50 microM) to inhibit 5'-nucleotidase activity increased AMP concentrations two- to threefold. Exposure to forskolin (100 microM) or ionomycin (2 microM) stimulated nucleotide release from cholangiocarcinoma but not hepatoma cells. These studies indicate that adenosine nucleotides are present in bile in concentrations sufficient to activate purinergic receptors. Purinergic receptor activation by local nucleotide release might constitute an autocrine and/or paracrine mechanism for modulation of biliary secretion.