Endoscopic balloon sphincteroplasty (papillary dilation) for bile duct stones: efficacy, safety, and follow-up in 100 patients.

BACKGROUND: Because sphincterotomy accounts for a major portion of the morbidity and mortality associated with ERCP, we have proposed endoscopic balloon papillary dilation or sphincteroplasty as an alternative. METHODS: We report the outcome in a series of 100 patients in whom balloon sphincteroplasty was attempted for bile duct stones up to 20 mm in diameter, with a median follow-up of 16 months (range 6 to 30). RESULTS: During one ERCP session using sphincteroplasty alone, the bile duct was cleared in 78%, mechanical lithotripsy being required in 10% for stones greater than 12 mm in diameter. Incomplete duct clearance was achieved in a further 4%, all of whom underwent repeat ERCP with successful duct clearance without recourse to sphincterotomy. Failure to clear the bile duct with sphincteroplasty in the remaining 18% was primarily related to large stone size ( > 15 mm). Sphincterotomy was required to clear the duct in 7%. Another 6% comprised elderly high-risk patients with multiple large stones greater than 15 mm who were treated by stent insertion plus ursodeoxycholic acid. No papillary hemorrhage was observed; uncomplicated pancreatitis occurred in 5%. During a median follow-up of 16 months, 2% had recurrent symptomatic bile duct stones considered to have been unrecognized following the initial ERCP: these were removed after repeat sphincteroplasty. No clinical evidence of papillary stenosis was observed during follow-up. CONCLUSIONS: Endoscopic balloon papillary dilation or sphincteroplasty is a safe and effective alternative to sphincterotomy in the management of bile duct stones less than 12 mm; larger stones may require mechanical lithotripsy to facilitate duct clearance.

A study of intracolonic hydrogen and methane levels during colonoscopy.

Gas samples were obtained during colonoscopy for analysis. Patients were prepared with polyethylene glycol (PEG) (N = 23), phosphate enema (N = 34) and mannitol (N = 4). Air insufflation was used in all procedures. High concentrations of hydrogen were detected in 3 out of 38 gas samples in the PEG group, in 2 of 41 samples in the phosphate enema group and in one of the 8 samples in the mannitol group. All patients had a coexisting intracolonic oxygen concentration > 5%. The results suggest that potentially explosive concentrations of hydrogen may occur after conventional bowel preparations, and that insufflation of carbon dioxide during polypectomy should be a routine.

Management of reflux oesophagitis: role of weight loss and cimetidine.

A double blind clinical trial was performed to evaluate the effect of weight loss and cimetidine in the treatment of reflux oesophagitis. Thirty-two patients were evaluated by endoscopy, L.O.S.P. determination, oesophageal scintigraphy and ambulatory 24 hour oesophageal pH monitoring. Patients were randomly allocated into treatment using a regimen of placebo/weight loss or cimetidine/weight loss. Assessments were repeated after 8-12 weeks. A similar weight loss and improvement in symptoms and endoscopy appearances was seen in both groups. In contrast there was no significant change in frequency or duration of reflux on 24-hour pH monitoring or oesophageal scintigraphy or L.O.S.P. We conclude that weight loss may have an important role in the treatment of reflux oesophagitis and should be recommended to patients as an early therapeutic intervention. Cimetidine did not confer any additional benefit to that obtained from weight loss alone.

Granulomatous hepatitis in secondary syphilis.

An unusual case of a well-documented granulomatous hepatitis in secondary syphilis in a 47-year-old male is presented. This hepatic pathology in secondary syphilis is summarised, and a review of the literature regarding syphilitic granulomatous hepatitis presented.

Chronic erosive gastritis: a clinical study.

In order to help clarify the clinical importance of chronic erosive gastritis, we describe our experience of 28 patients with this disorder who were seen over a 2-yr period. Twenty patients were male. Twenty-four patients presented with abdominal pain, for which no cause other than chronic erosive gastritis was found in 20 patients. Ten patients had pain for more than 1 yr. Three patients presented with painless vomiting. The antrum was involved in 27 patients and the body in 17 patients. There was no correlation between the number of erosions and the duration of symptoms. Double contrast barium meal was positive in nine of 21 patients. Of 19 patients treated with cimetidine, 15 improved clinically and six of eight had endoscopic improvement. The treatment of choice is unknown and controlled trials are needed. Symptoms in patients with chronic erosive gastritis appear to be due to the gastritis itself rather than to associated lesions.

Successful treatment of a post-operative external biliary fistula by endoscopic papillotomy.

A patient presenting with a bile collection in his abdominal wound following an oesophagogastrectomy was found to have an external biliary fistula. The obstruction in the common bile duct was due to gallstones. The patient underwent endoscopic papillotomy and his fistula closed without further surgery.

Atraumatic non-distorting pyloric sphincter pressure studies.

Conflicting claims have been made regarding the physiological characteristics of the pyloric sphincter. Pyloric sphincter pressures were studied in 32 patients under basal conditions, after stimulation with HCl and posture changes. At gastroscopy a 2 mm diameter manometer catheter was placed in the duodenum and three to five hours later the catheter was withdrawn slowly with continuous manometry. Lower esophageal sphincter pressures fell within the expected range but there was no definite evidence of a pressure barrier at the pylorus in any group of patients. The technique caused no patient discomfort and minimal distortion of the region under study, indicating that the pylorus is usually patent with a lumenal diameter greater than 2 mm.