Experience with endoluminal colonic wall stents for the management of large bowel obstruction for benign and malignant disease.

HYPOTHESIS: To assess the applicability and efficacy of endoluminal colonic wall stents (ECWSs) in the management of large bowel obstruction (LBO). DESIGN: Inception cohort study. SETTING: University-based tertiary medical center. PATIENTS: Eleven consecutive patients with LBO in the absence of peritonitis. INTERVENTION: Placement of ECWS under endoscopic and fluoroscopic guidance. MAIN OUTCOME MEASURES: The success rate in ECWS placement, the efficacy in decompressing the obstruction, and the patency rate of the ECWS. RESULTS: Successful placement of ECWSs was obtainable in 10 of 11 patients. Once placed, all 10 patients achieved immediate decompression of their LBO. Eight patients had malignant obstructions associated with distant spread of disease; 3 patients had diverticular disease. Among those with malignant obstruction, 6 patients had successful and lasting palliation without colostomy, 1 patient underwent 1-stage resection 1 month later with no evidence of obstruction, and 1 patient could not be stented so diversion was done. None of the patients with diverticular disease required diversion: 2 had complete bowel preparation followed by resection with primary anastomosis, whereas the third declined surgery. Four of the 10 patients required overlapping ECWSs to bridge the stricture. One patient required a second ECWS secondary to recurrence of obstruction after stent migration and has continued palliation of his stage 4 rectal cancer for the last 11 months. No other complications were encountered. CONCLUSIONS: Urgent surgery with colostomy for LBO was avoided in 10 of 11 patients because of successful placement of ECWSs. We believe that endoscopic colonic stenting is safe, effective, and lasting, and should be considered as initial nonoperative management in all patients seen with LBO in the absence of peritonitis.

Evaluation of the clinical impact of endoscopic ultrasonography in gastrointestinal disease.

BACKGROUND: Outcome studies evaluating the impact of endosonography on patient management are lacking. We conducted a prospective study to assess the overall clinical effectiveness of endosonography as perceived by the requesting physician. METHODS: Physicians requesting endosonography were asked to fill out a questionnaire listing clinical diagnosis, diagnostic certainty, and future management plans. After the procedure, the requesting physicians were asked about changes in diagnosis and management, and the physicians' impressions of how clinically helpful the test was. Comparisons were made between the preprocedure and postprocedure assessment and plans, changes in diagnosis, diagnostic certainty, patient management plans, and if endosonography led to a more or less invasive course of therapy. RESULTS: Sixty-three patients (35 women and 28 men) were evaluated. Management was altered in 30 patients (48%). In 66% of these patients the subsequent course of therapy was less invasive. Diagnostic certainty increased from 2.8 before endosonography to 4.3 after sonography (p = 0.0001). Endosonography was judged to be 4.1 on a "usefulness" score of 1 to 5. CONCLUSIONS: Endosonography is helpful in improving diagnostic certainty, frequently leading to altered patient management, and is perceived to be a helpful test by requesting physicians.

Gastrobronchial fistula in untreated lymphoma.

A 48-year-old man with B-cell lymphoma of the stomach was seen with recurrent pneumonia, weight loss, and anorexia. A barium study revealed a large malignant gastric ulcer with a gastrobronchial fistula. A computed tomography (CT) scan of the abdomen showed a gastric neoplasm invading the left lower lobe of the lung and the spleen.

Endoscopic ultrasound appearance of watermelon stomach.

Gastric antral vascular ectasia (GAVE) seen endoscopically has characteristic thickened, red vascular folds radiating from the pylorus to the antrum. The endoscopic ultrasound findings are described and correlated with the visual appearance, computed tomographic (CT) scans, and histologic findings. Hyperechoic focal thickening of the inner layers of the gastric wall are noted and may reflect the diagnosis of GAVE.

Magnetic resonance imaging of an infected urethral diverticulum: a case report.

We present a case report of a urethral diverticulum where magnetic resonance imaging suggested infected contents of the urethral diverticulum besides providing superb detail of periurethral anatomy. The critical clinical question was answered.

Dipstick evaluation of hematuria in abdominal trauma.

Urine microscopic evaluation of hematuria has traditionally been used to determine the need for an intravenous pyelogram (IVP) in individuals with blunt abdominal trauma. An IVP is generally advocated in cases where greater than 5-10 red blood cells per high power field (RBC/HPF) are identified. Various laboratories have advocated the use of dipstick examination of these urine specimens as a replacement for microscopic examination. Urine specimens from 178 consecutive patients with blunt abdominal injury were evaluated by dipstick (Chemstrip 9, Cat. No. 417190, Boehringer Mannheim Diagnostics) and microscopic examination. Sensitivity of dipstick testing for microscopic hematuria was 100% as compared to microscopic examination (positive greater than or equal to 5RBC/HPF); specificity was 58.6%. Predictive value of a positive test (PVP) was 60.8%; predictive value of a negative test (PVN) was 100%. Evaluation of proteinuria performed as an additional means of assessing renal integrity was found to be less sensitive, but more specific than, dipstick evaluation of hematuria. Poor correlation was seen between the degree of positivity by dipstick testing and the actual degree of microscopic hematuria. It is concluded that specimens which are negative for hematuria by dipstick do not need further testing by microscopic examination. All specimens which contain blood by dipstick evaluation need to be examined microscopically to predict the need for IVP.