The utility of EUS and EUS-guided fine needle aspiration in detecting celiac lymph node metastasis in patients with esophageal cancer: a single-center experience.

BACKGROUND: The aims of this study were to determine the utility of EUS and EUS-guided fine needle aspiration (EUS-FNA) in the detection and confirmation of celiac lymph node metastasis in patients with esophageal cancer and to define EUS features predictive of celiac lymph node metastasis in these patients. METHODS: The records of 211 patients with esophageal cancer who underwent EUS staging were reviewed. The operating characteristics of EUS were determined in patients where either surgery, EUS-FNA of a celiac lymph node, or both were performed (n = 102). The association between selected variables and the presence of celiac lymph node metastasis was evaluated by univariate and multivariable analyses. RESULTS: EUS in 48 patients provided a true-positive diagnosis of celiac lymph node involvement, a false-positive and false-negative result, respectively, in 6 and 14 patients, and a true-negative diagnosis in 34 patients. The sensitivity of EUS in detecting celiac lymph node was 77% (95% CI [67, 88]), specificity 85% (95% CI [74, 96]), negative predictive value 71% (95% CI [58, 84]), and the positive predictive value 89% (95% CI [81, 97]). EUS-FNA was performed in 94% (51/54) of patients with celiac lymph nodes. The accuracy of EUS-FNA in detecting malignant celiac lymph nodes was 98% (95% CI [90, 100]). Advanced T-stage, the need for dilation, detection of peritumoral lymph nodes, and black race were associated with celiac lymph node involvement. In multivariable analysis, advanced T-stage was the strongest predictor of celiac lymph node involvement. CONCLUSION: EUS and EUS-FNA are highly accurate in detecting and confirming celiac lymph nodes metastasis. Depth of tumor invasion as assessed by EUS is a strong predictor of celiac lymph node metastasis in patients with esophageal cancer.

CT or EUS for the initial staging of esophageal cancer? A cost minimization analysis.

BACKGROUND: Patients with advanced (T4 and/or M1) esophageal cancer are offered palliative therapy. Computed tomography (CT) is sensitive for distant metastases but is less sensitive than endosonography for T4 disease and celiac lymphadenopathy. The aim of this study was to determine whether initial CT or endosonography costs less to diagnose advanced esophageal cancer. METHODS: A decision model compared the costs of the 2 strategies. Sensitivity analysis and threshold analysis were used to identify the most important determinants of the overall cost of identifying advanced disease. RESULTS: Initial CT is the least costly strategy if the probability of finding advanced disease by initial CT is greater than 20%, if the probability of finding advanced disease by initial endoscopic ultrasound (EUS) is less than 30%, or if the cost of EUS is greater than 3.5 times the cost of CT. However, in our referral center population, endosonography found advanced disease more frequently than CT (44% vs. 13%; p < 0.0001) and the least costly strategy was initial endosonography (expected cost $804 vs. $844). CONCLUSION: CT remains as the initial staging test of choice in most clinical settings. However, in referral centers, initial EUS may be reasonable, but individualized model inputs must be obtained before reliable conclusions can be drawn.

EUS to detect evidence of pancreatic disease in patients with persistent or nonspecific dyspepsia.

BACKGROUND: Mild chronic pancreatitis is difficult to diagnose and the diagnosis is therefore not sought routinely in patients with dyspepsia. The aim of our study was to compare the prevalence of endosonographic pancreatic abnormalities in patients with dyspepsia and control subjects. METHODS: The number of endosonographic abnormalities was compared prospectively in patients with dyspepsia and control patients. Patients in whom there was any suspicion of pancreatic disease were analyzed separately. RESULTS: Between November 1998 and January 1999, 156 patients with dyspepsia were compared with 27 control patients. The groups were similar except that control patients were significantly older and more likely to be men. The mean number of endosonographic abnormalities was higher in dyspeptic patients than in control patients (mean number of abnormalities 3.3: 95% CI [2.9, 3.6] vs. 1.9: 95% CI [0.3, 1.7]). The strongest independent predictors of severe endosonographic abnormalities (defined as 5 or more abnormalities) were the presence of suspected pancreatic disease (odds ratio 7.29: 95% CI [2.03, 26. 14]) and dyspepsia (odds ratio 7.21: 95% CI [1.99, 26.26]). In the dyspepsia group, no clinical variables were significant predictors of severe abnormalities. However, most patients had nonspecific-type dyspepsia or persistent symptoms after therapeutic trials of acid suppression. CONCLUSIONS: Dyspepsia may be an atypical presentation of pancreatic disease in patients with persistent or nonspecific symptoms. Endosonography may be useful to screen for pancreatic disease in patients with persistent dyspepsia.

Prophylaxis for stress-related gastric hemorrhage in the medical intensive care unit. A randomized, controlled, single-blind study.

OBJECTIVE: To determine the efficacy and safety of cimetidine and sucralfate prophylaxis for stress-related gastrointestinal hemorrhage in patients admitted to a medical intensive care unit. SETTING: Medical intensive care unit of a nonprofit, university-affiliated teaching hospital. PATIENTS: 300 patients admitted to the medical intensive care unit during a 10-month period. DESIGN: Randomized, controlled, single-blind clinical trial. INTERVENTION: Patients were assigned to receive no prophylaxis (control), 1 g sucralfate given orally every 6 hours, or continuous intravenous cimetidine titrated to maintain gastric pH at 4.0, intervention was maintained until the occurrence of clinically severe hemorrhage, onset of drug-related complications, death, or discharge from the medical intensive care unit. OUTCOME MEASURES: The primary outcome measure was the incidence of clinically severe hemorrhage from endoscopically verified stress-related gastritis. Other outcome measures were transfusion requirements, duration of medical intensive care unit stay, incidence of nosocomial pneumonia, adverse drug reactions, and death. RESULTS: 100 patients were randomly assigned to each treatment. The three groups were similar with regard to demographic characteristics, intensive care unit admission diagnoses, and APACHE II scores. Stress-related hemorrhage was seen in 6% of control participants and in 5% of those receiving sucralfate or cimetidine (relative risk compared with control, 0.83 for each group; 95% CI, 0.26 to 2.64; P = 0.75). No statistically significant differences were found for transfusion requirements, duration of medical intensive care unit stay, and mortality rates among the three groups. Nosocomial pneumonia was diagnosed in 6%, 12%, and 13% of controls, sucralfate recipients, and cimetidine recipients, respectively (sucralfate: relative risk, 2.0 [CI, 0.79 to 5.01], P = 0.14; cimetidine: relative risk, 2.2 [CI, 0.88 to 5.33], P = 0.09). Prophylaxis caused no definite adverse drug reactions. CONCLUSIONS: The observed effects of cimetidine and sucralfate on the incidence and severity of hemorrhage from stress-related gastritis were not significant when compared with no treatment. Routine prophylaxis with these agents for patients entering the medical intensive care unit does not seem warranted.

Myenteric plexus destruction alters morphology of rat intestine.

BACKGROUND: It has been shown previously that myenteric plexus destruction by benzalkonium chloride (BAC) increased villus height, crypt depth, and muscle thickness, suggesting that these neurons influence intestinal morphology. A nonspecific trophic effect of BAC, intraluminal stasis, and inflammation resulting from the chemical treatment could also be causes for these changes. Our goals were to (1) show that the morphological sequelae of BAC treatment are caused by myenteric plexus removal and not the factors listed above, and (2) determine whether segmental myenteric plexus removal alters morphology elsewhere in the small intestine. METHODS: Six groups of rats were studied: control, chemical denervation (3 mmol/L BAC), surgical denervation, intraluminal stasis produced by partial obstruction, chemical inflammation (5% acetic acid), and surgical inflammation (serosa removal only). Tissue for histological study was taken from the treated segment, 15-20 cm proximal to the treated segment, and 5-10 cm distal to the treated segment 28 days after treatment. RESULTS: Chemical and surgical denervation reduced the number of myenteric neurons by 94% and 98%, respectively. Denervation had a direct effect on morphology; it increased villus height, crypt depth, and muscle thickness in the treated and proximal segments, but only muscle thickness was increased in the distal segment. The other treatments had minimal morphological sequelae. CONCLUSIONS: Segmental myenteric plexus removal alters the mucosa in the treated and proximal segments but influences muscle thickness throughout the intestine.

[Chronic changes in the liver in our patients]. / Kronicne promjene jetre kod nasih bolesnika.

VHB infection together with alcohol ist the most important ethiologic factor in the genesis of chronic liver parenchyma damage in our sample. Selection of patients with chronic diseases of the liver should be done on the basis of hepatitis markers determination, that is on the presence of HBsAg and HBeAg and the activity of aminotransferases in blood. Doing this it can be seen that more that half of the patients with chronic liver damage do not need therapy, and they have work capacity preserved. In these cases occasional controls of hepatitis markers and the level of AT in blood are needed. Presence of the virus replication can be determined on the basis of presence of the HBeAg in blood and HBcAg in the hepatocyte nucleus (histologic assay), since HBV-DNA and HBV-DNA polymerases in blood are not determined in the day's routine. Biopsy and rebiopsy of the liver tissue (pathohistologic assay) is the only confident my to determine the degree of liver damage. Introducing of the unique criteria in the management of the patients who have the signs of chronic liver damage would lower the diagnosis and treatment costs, as well as the unnecessary patient's absence from work. Proceeding of the preventive measures, vaccination of the persons who are exposed to VHB infection, as well as the struggle against alcoholism, stay on as the main source in prevention of chronic liver damage genesis.