Black esophagus: report of six cases and review of the literature, 1963-2003.

Black esophagus is the uncommon endoscopic finding of extensive black discoloration of the esophageal mucosa, usually from acute esophageal necrosis. Six cases of black esophagus were seen at Mayo Clinic (Rochester, Minnesota, USA) from 1997 through 2003, and 46 cases were reported in the English-language literature from 1963 through 2003. We studied the demographics, clinical features, and outcomes of these 52 cases of black esophagus. Age and sex were known for 50 patients: the mean (SD) age was 65 years (19), and 42 patients (84%) were men. Symptoms were known for 51 patients: the most common symptom was upper gastrointestinal tract bleeding, occurring in 40 patients (78%). All 52 patients had at least one comorbid condition (with most having two or more), including duodenal ulcer in 17 (33%), cancer in 15 (29%), renal insufficiency in 15 (29%), and diabetes mellitus in 14 (28%). The suspected cause of black esophagus was reported for 40 patients: ischemia in 22 (55%); massive gastroesophageal reflux in seven (18%); and esophageal infection (Lactobacillus acidophilus, herpes simplex, Candida albicans) in four (10%). Most patients received supportive therapy, particularly acid suppression therapy. Of the 47 patients for whom outcomes were known, 17 (36%) died. There were no statistically significant differences between survivors and non-survivors. Black esophagus typically occurs in older men with at least one comorbid condition; a substantial number of patients die. Although the underlying mechanism leading to black esophagus is unknown, clinicians caring for patients with black esophagus should focus on optimizing perfusion, minimizing acid reflux, and treating esophageal infection if present.

Assessing professionalism in early medical education: experience with peer evaluation and self-evaluation in the gross anatomy course.

INTRODUCTION: As today's healthcare model moves toward more streamlined and corporate industrialism, it is our responsibility, as doctors, to ensure the integrity of medicine's foundation in professionalism. The erosion of professional values not only creates a climate of animosity, but reverberates negatively to impact the development of students, who model their behaviour after those they most respect. This hazard has spurred an evaluation of medical school curricula, with a new emphasis on professionalism in the philosophy of medical education. Courses such as Gross Anatomy that, in the past, offered "pure content," are now being used to teach and evaluate professionalism. The goal of this study was to determine if peer evaluation and self-evaluation used in conjunction and implemented early in the medical curriculum, can serve as useful tools to assess and provide feedback regarding professional behaviour in first-year medical students. MATERIALS AND METHODS: From 1999 to 2003, students at Mayo Clinic College of Medicine evaluated themselves and their peers during the Gross and Developmental Anatomy Course. Numerical evaluations and written comments were statistically analysed within established categories of professionalism and correlated with academic performance, gender, and peer rating and self-rating. RESULTS: The majority of written comments pertained to inter-professional respect, responsibility, and excellence. Students who gave higher peer evaluation and self-evaluation scores provided more positive comments, and students performing well in the course provided more positive comments about their peers and themselves than did those struggling academically. Students consistently rated their peers higher than themselves, and male students rated themselves higher than did female students. CONCLUSIONS: Implementing peer evaluation and self-evaluation early in the medical curriculum is a valuable exercise in teaching first-year medical students assessment skills when evaluating their behaviour, as well as the behaviour of their colleagues.

Endoscopic YAG laser treatment of watermelon stomach (gastric antral vascular ectasia) in patients with systemic sclerosis.

OBJECTIVE: Gastric antral vascular ectasia (GAVE) has been recognized as a rare but important cause of chronic iron deficiency anemia. A number of reported patients were found to have evidence of autoimmune disorders or connective tissue diseases. We carried out this study in order to determine the clinical, endoscopic, and pathologic features in a large series of patients with systemic sclerosis (SSc) who were diagnosed with GAVE. We also determined the response to YAG laser treatment for chronic blood loss in these patients. METHODS: A retrospective chart review of 20 cases diagnosed over an 11-year period, with diagnoses of both SSc and GAVE. RESULTS: Twenty patients with SSc presented with prominent anemia and were diagnosed with GAVE. Treatment with endoscopic laser therapy was successful in preventing surgery for bleeding in GAVE in 85% of cases. CONCLUSIONS: GAVE should be considered in patients with SSc who develop chronic iron deficiency anemia. YAG laser treatment can be useful in the treatment of chronic blood loss anemia in SSc patients with GAVE.

The Mayo Clinic's Clinician-Educator Award: A program to encourage educational innovation and scholarship.

In 1998, the Board of Governors of the Mayo Clinic requested that the Education Committee design and implement a program to grant time and resources to clinical faculty to support the development of educational projects. The essence of the resulting Clinician-Educator Award Program is the concept of using funding to award time and resources for educational projects judged to be meritorious by an impartial, peer-review-based faculty mentoring process. The authors report early experiences with the program, which was enthusiastically accepted by faculty, to provide a model to help other academic health centers, especially those with salary-based faculty, to facilitate educational innovation and scholarship despite the growing constraints on academic clinicians' time and resources.

A new syndrome of Crohn's disease and pachydermoperiostosis in a family.

Few syndromic associations with Crohn's disease are described. The aim of this study was to characterize a new syndrome of Crohn's disease associated with pachydermoperiostosis in 3 brothers. Three probands, 6 siblings, both parents, 20 of 21 third-generation relatives, and 9 spousal controls were evaluated. Serological evaluation for antineutrophil cytoplasmic antibodies and human leukocyte antigens as well as genetic testing for tumor necrosis factor microsatellites, intercellular adhesion molecule 1 polymorphisms, the interleukin 1 receptor antagonist gene, and the interleukin 1 beta gene were performed. Only the 3 probands were affected and developed pachydermoperiostosis between ages 14 and 17 years. Pachydermoperiostosis preceded Crohn's ileocolitis by 6 and 20 years in two probands, excluding secondary hypertrophic osteoarthropathy. Two probands were antineutrophil cytoplasmic antibody positive vs. 1 of 27 unaffected relatives (P < 0.001, chi 2). Haplotypes for human leukocyte antigen and tumor necrosis factor microsatellites were discordant. The probands' generation was homozygous for the common allele 1 of the interleukin 1 receptor antagonist and interleukin 1 beta genes. Two probands carried a rare polymorphism of the intercellular adhesion molecule 1 gene. A new syndrome of Crohn's disease and pachydermoperiostosis associated with antineutrophil cytoplasmic antibodies is described. Inheritance is most likely autosomal recessive by pedigree. No clear association was found between this syndrome and the gene regions evaluated.

Does performance status influence the outcome of Nd:YAG laser therapy of proximal esophageal tumors?

The value of endoscopic palliative therapy for malignant obstruction in the proximal esophagus has been questioned. To assess the importance of pre-treatment performance status on treatment outcome, we reviewed the records of patients with tumors of the proximal esophagus undergoing endoscopic laser therapy between January 1986 and December 1988. As compared with 10 patients having a good performance status, eight patients with a poor performance status had a lower frequency of obtaining complete functional relief of dysphagia (14% versus 71%), an increased rate of complications (50% versus 0%), and a shorter median survival time (24 days versus 161 days). We conclude that performance status should be considered in determining the appropriateness of laser therapy in patients with proximal esophageal cancer.

Acute gastrointestinal bleeding from portal hypertensive gastropathy: prevalence and clinical features.

The clinical and endoscopic features of patients diagnosed with acute bleeding due to portal hypertensive gastropathy (PHG) were evaluated. Acute bleeding from PHG was diagnosed in 12 patients (0.8%) of 1496 patient admissions prospectively evaluated by our Gastrointestinal Bleeding Team over a 3-yr period, and accounted for 8% of nonvariceal bleeding diagnosed in patients with liver disease. The median age of PHG patients (8M:4F) was 66 yr (range, 37-72). The most common underlying liver disease was alcoholic cirrhosis (five patients). The majority of patients presented with melena. There was no hemodynamic instability. Six patients had prior sclerotherapy. Esophageal varices, grades 1 (five patients) and 2 (three patients), were present. Severe PHG was encountered in seven patients. There was no correlation between the presence or absence of varices, the grade of esophageal varices, and prior sclerotherapy on the severity of PHG or continued bleeding. The mean hospital stay was 6 days. An average of 4 units of blood was transfused per patient (range, 2-8). Continued bleeding occurred in nine patients (75%), one of whom had mild PHG. Two patients with continued bleeding subsequently were diagnosed with portal hypertensive vasculopathy distal to the stomach. There was one episode of encephalopathy and no related mortality. Acute (overt) bleeding from PHG is uncommon, likely to recur, and can evolve into a pattern of chronic blood loss.

Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon.

UNLABELLED: Endoscopic laser coagulation effectively controls bleeding from radiation-induced rectal vascular lesions. OBJECTIVE: To assess the outcome of endoscopic treatment of radiation-induced bleeding due to vascular lesions located proximal to the sigmoid colon. METHODS: We identified 15 consecutive patients with such proximal radiation enteropathy treated at our Institution with Nd:YAG laser between 1984 and 1991. Ten patients (66%) had gastric and/or small bowel involvement, and five (33%) had colonic involvement with or without more proximal lesions. Bleeding first appeared at a mean of 21.2 +/- 12.5 months after completion of radiotherapy. Mean duration of gastrointestinal bleeding before laser treatment was 7.6 +/- 4.6 months. RESULTS: After completion of laser therapy, bleeding ceased in nine (60%) patients, decreased in three (20%), and persisted in three (20%). The mean hemoglobin level increased from 8.4 +/- 0.5 g/dl to 10.4 +/- 0.6 g/dl after completion of laser treatments (p < 0.02). The mean number of transfusions per patient per year decreased from 10.5 +/- 2.8 to 0.9 +/- 0.7 (p < 0.01). No treatment-related complications or deaths occurred. CONCLUSIONS: Endoscopic laser coagulation of radiation-induced mucosal vascular lesions in the upper gastrointestinal tract and proximal colon appears to be safe and, in most cases, effective.

Endoscopic Nd:YAG laser coagulation of bleeding from radiation proctopathy.

Hematochezia from mucosal vascular lesions usually confined to the rectum represents an uncommon but problematic late complication of pelvic radiotherapy. We studied 47 patients with medically refractory hematochezia resulting from radiation-induced rectosigmoid mucosal vascular lesions. All lesions were endoscopically coagulated with Nd:YAG laser. Median duration of hematochezia before laser therapy was 11 months, despite previous medical treatment (98%) or bypass colostomy (6%). Within 3 to 6 months after laser treatment, the number of patients with daily hematochezia fell from 40 (85%) to 5 (11%; p < 0.001), and the median hemoglobin level increased from 9.7 gm/dl to 11.7 gm/dl (p < 0.001). Complications occurred in three patients (6%); no deaths occurred. The condition in six patients (12.8%) was not improved by laser treatment. Two patients (4%) ultimately required surgical treatment for bleeding control. On the basis of symptomatic, hematologic, and endoscopic responses, Nd:YAG laser photocoagulation controlled bleeding from radiation proctopathy in most patients with an acceptably low morbidity. Patients with sigmoid colon involvement responded less favorably. Endoscopic laser photocoagulation should be considered before surgical intervention for treatment of hematochezia from radiation proctopathy.

The clinical and endoscopic spectrum of the watermelon stomach.

The watermelon stomach is an uncommon but treatable cause of chronic gastrointestinal bleeding. We report our experience with the clinical and endoscopic features of 45 consecutive patients treated by endoscopic Nd:YAG laser coagulation. The prototypic patient was a woman (71%) with an average age of 73 years (range of 53-89 years) who presented with occult (89%) transfusion-dependent (62%) gastrointestinal bleeding over a median period of 2 years (range of 1 month to > 20 years). Autoimmune connective tissue disorders were present in 28 patients (62%), especially Raynaud's phenomena (31%) and sclerodactyly (20%). Atrophic gastritis occurred in 19 of 19 (100%) patients, with hypergastrinemia in 25 (76%) of 33 patients tested. Antral endoscopic appearances included raised or flat stripes of ectatic vascular tissue (89%) or diffusely scattered lesions (11%). Proximal gastric involvement was present in 12 patients (27%), typically in the presence of a diaphragmatic hernia. Endoscopic laser therapy after a median of one treatment (range of 1-4) resulted in complete resolution of visible disease in four patients (13%) and resolution of > 90% in 24 patients (80%). Hemoglobin levels normalized in 87% of patients over a median follow-up period of 2 years (range of 1 month to 6 years) with no major complications. Blood transfusions were not necessary after laser therapy in 86% of 28 initially transfusion-dependent patients. The characteristic clinical, laboratory, and endoscopic features allow for a confident diagnosis that can lead to successful endoscopic treatment.

Portal hypertensive intestinal vasculopathy: a review of the clinical, endoscopic, and histopathologic features.

Over the past decade, awareness of the association between portal hypertension and changes in the intestinal circulation has increased. Most of the observations have been made by endoscopic examination and biopsy of the mucosa. The fundamental pathologic change is a vasculopathy. Portal hypertensive intestinal vasculopathy (PHIV) most often involves the stomach (gastropathy) and can be a common source of bleeding. The significance of small bowel involvement (enteropathy) is unknown. Colon involvement (colopathy) has been associated with bleeding, and mimics inflammatory bowel disease. The reliability of endoscopic appearances and histologic examination in establishing the diagnosis is questionable. Recent observations of other diagnostic modalities and associated physiologic alterations and treatment options are discussed. Further prospective evaluations that use uniform terminology for endoscopic and histologic descriptions are needed to establish criteria for accurate diagnosis and assessment of response to treatment.

Acute gastrointestinal bleeding. Experience of a specialized management team.

The initial experience of a specialized management team organized to provide expedient care for all acute major gastrointestinal bleeding in protocolized fashion at a large referral center is presented. Of the 417 patients, 56% developed bleeding while hospitalized. Upper gastrointestinal bleeding accounted for 82%. The five most common etiologies included gastric ulcers (83 patients), duodenal ulcers (67 patients), erosions (41 patients), varices (35 patients), and diverticulosis (29 patients). Nonsteroidal anti-inflammatory drugs were implicated in 53% of gastroduodenal ulcers. The incidence of nonbleeding visible vessels was 42% in gastric and 54% in duodenal ulcers. The rates of rebleeding were 24% (20 patients) in gastric ulcers and 28% (19 patients) in duodenal ulcers. Predictive factors for rebleeding included copious bright red blood, active arterial streaming, spurting, or a densely adherent clot. The rebleeding rate for esophagogastric varices was 57%. The mortality rate overall was 6% (27 patients), with rates varying from 3% (five patients) for gastroduodenal ulcers to 40% (14 patients) for esophagogastric varices. The morbidity rate for the entire patient population was 18% (77 patients), dominated by myocardial events (34 patients). The average length of hospitalization for gastroduodenal ulcers was 5 days, for diverticulosis 8 days, and for varices 10 days. The major efforts of a specialized Gastrointestinal Bleeding Team would be best directed at both reducing the morbidity associated with acute bleeding and reducing the overall cost of care.

Treatment of benign esophageal stricture by Eder-Puestow or balloon dilators: a comparison between randomized and prospective nonrandomized trials.

To determine whether the natural history of strictures is affected by the type of dilator used to treat newly diagnosed peptic strictures, we designed a prospective randomized trial to compare the results after Eder-Puestow or Medi-Tech balloon dilation. We entered 31 patients into the trial. We also prospectively followed up all 92 nonrandomized patients who underwent their first dilation for a benign stricture during the same period as the prospective randomized trial. The nonrandomized patients also underwent dilation with either the Eder-Puestow or the balloon technique at the discretion of the gastroenterologist performing the endoscopy. We found no statistically significant differences in the immediate or long-term results of the two methods among the randomized, nonrandomized, and overall combined groups. All but 1 of the 123 patients had immediate relief of dysphagia. Within each group of patients, the probability of remaining free of dysphagia 1 year after the initial dilation was approximately 20%, and the probability of not requiring a second dilation was approximately 65% with either technique. Major (esophageal rupture) and minor (bleeding or chest pain) complications occurred in 1% and 5% of the patients and 0.4% and 3% of the total dilation procedures, respectively. The esophageal rupture and four of six minor complications occurred after repeated dilations. Five of the six minor complications occurred with use of the Eder-Puestow dilators. We conclude that Eder-Puestow and balloon dilations of benign esophageal strictures are associated with similar outcomes, but repeated dilations and the Eder-Puestow technique may be associated with an increased risk of complications.

Prospective comparison of contact with noncontact Nd:Yag laser therapy for palliation of esophageal carcinoma.

Twenty patients with dysphagia due to inoperable esophageal cancer were randomized to receive either contact or noncontact endoscopic laser treatment. Treatment groups were similar with respect to age, dysphagia score, and tumor dimensions. The median number of initial treatment sessions was two in both groups, and the median treatment times per session were 23 min (range, 12 to 55 min) in the contact group and 19 min (range, 5 to 28 min) in the noncontact group. Median dysphagia scores were also similar in both groups 1 month after laser treatment, and no difference was apparent in the duration of palliation. There were no patient complications attributable to laser therapy, but damage to the laser wave guide occurred in three contact sessions and two noncontact sessions. These data suggest no advantage for the contact method of endoscopic Nd:YAG laser palliation of esophageal carcinoma with respect to number of treatment sessions, relief of dysphagia, or occurrence of complications.

Endoscopic laser therapy for watermelon stomach.

Thirteen patients (9 women, 4 men) with anemia from acute and chronic gastrointestinal bleeding were found to have antral vascular disease consistent with watermelon stomach. The median age was 73 yr, with a range of 54-88 yr. Eight of the patients were transfusion-dependent, requiring a median of 5.5 U within the 12 mo before treatment. All were treated with endoscopic neodymium:yttrium-aluminum-garnet laser coagulation. Endoscopic and hematologic improvement were evident in 12 patients available for follow-up after a median period of 6 mo. There was a median increase of 4 g/dl in hemoglobin concentration; thus, the need for transfusion was eliminated. No major complications were encountered. Laser coagulation for watermelon stomach appears to be safe and efficacious and may be a therapeutic alternative for this disorder.