Radiofrequency ablation of Barrett's esophagus: outcomes of 429 patients from a multicenter community practice registry.

BACKGROUND AND STUDY AIMS: The use of radiofrequency ablation (RFA) for complete eradication of Barrett's esophagus has shown promise in trials conducted at predominantly tertiary academic centers; however less is known regarding outcomes in the community. We evaluated the safety and efficacy of RFA for Barrett's esophagus delivered in a community practice setting. PATIENTS AND METHODS: This was a multicenter registry conducted in community-based gastroenterology practices. Patients had confirmed intestinal metaplasia with or without dysplasia on biopsy of a Barrett's esophagus. Intervention was step-wise RFA with follow-up esophageal biopsies. Endpoints were histology-based; complete response was defined as all biopsies at most recent endoscopy negative for intestinal metaplasia (CR-IM) or dysplasia (CR-D). Three cohorts were reported: 1) safety cohort, all patients; 2) efficacy cohort A, patients with at least one biopsy session after initial treatment; 3) efficacy cohort B, patients with at least one biopsy session > or = 1 year after initial treatment. RESULTS: The safety cohort included 429 patients (71 % men, median age 59 years, median Barrett's segment 3.0 cm). There were no serious adverse events (bleeding, perforation, death), and a stricture occurred after 1.1 % of cases (2.1 % of patients). In efficacy cohort A (n = 338), CR-IM and CR-D were achieved in 72 % and 89 % of patients, respectively (median follow-up 9 months). In efficacy cohort B (n = 137), CR-IM and CR-D were achieved in 77 % and 100 % of patients, respectively (median follow-up 20 months). CONCLUSIONS: In this multicenter registry conducted at four community-based practices, the observed safety and efficacy outcomes associated with RFA for Barrett's esophagus are comparable to those previously reported in multicenter trials from predominantly tertiary academic centers.

The spectrum and natural history of common bile duct stenosis in chronic alcohol-induced pancreatitis.

Sixty patients with chronic alcohol-induced pancreatitis with endoscopic retrograde cholangiopancreatography evidence of common bile duct stenosis were studied to determine the clinical spectrum and natural history of this complication, as well as the indications for biliary bypass. In 17% of patients, common bile duct stenosis (CBDS) was an incidental finding at ERCP, while in the remaining cases pain and jaundice were the predominant symptoms in 35% and 48%, respectively. Biliary drainage was performed in 38% of patients for persistent or recurrent jaundice, cholangitis, and while undergoing pancreatic duct or cyst drainage procedures for pain. The benign nature of CBDS in chronic alcohol-induced pancreatitis (CAIP) in patients without persistent jaundice is emphasized. In particular, no histologically proved cases of secondary biliary cirrhosis were noted. The majority of patients with CBDS due to CAIP may be safely managed without biliary bypass but require close follow-up.

Diagnostic value of ascites adenosine deaminase in tuberculous peritonitis.

The value of ascitic fluid adenosine deaminase activity in distinguishing tuberculosis from other causes of ascites was examined in a retrospective study of 41 patients with bacteriologically confirmed tuberculous peritonitis and 41 control patients, matched for age and sex, with ascites of other causes (12 alcoholic cirrhosis, 5 cryptogenic cirrhosis, 12 malignant disorders, 3 pancreatitis, and 9 miscellaneous causes). The mean ascites adenosine deaminase activity was 99.8 (SD 49.1) in tuberculous patients and 14.8 (8.4) U/l in control patients (p less than 0.0001). A cutoff of 32.3 U/l had a sensitivity of 95% and specificity of 98% in distinguishing between the two groups. In a subsequent prospective study of 64 patients with ascites, 11 were found to have tuberculosis. Of the others, 23 had cirrhosis (18 alcoholic, 5 cryptogenic), 17 malignant disorders, 3 pancreatitis, 5 cor pulmonale, 3 congestive cardiac failure, 1 systemic mastocytosis, and 1 renal failure and hypothyroidism. The mean ascites adenosine deaminase activity was 112.6 (45.0) U/l in the patients with tuberculous ascites and 16.3 (36.7) U/l (p less than 0.0001) in those with ascites of other causes. In this study, adenosine deaminase had a sensitivity of 100% and specificity of 96% in discriminating tuberculosis from other causes of ascites. These findings suggest that the ascitic fluid adenosine deaminase activity may be used to identify patients in whom the diagnosis of abdominal tuberculosis must be pursued.

The role of colonoscopy in the diagnosis of tuberculosis.

The value of colonoscopy in the diagnosis of ileocolonic tuberculosis at Groote Schuur Hospital was assessed and the published world experience reviewed. During a 4-year period, abdominal tuberculosis was diagnosed in 94 patients, of whom 18 manifested involvement of the ileocecal area and/or colon. Colonoscopy, performed in 10 of these, provided diagnostic information in 7. Since the endoscopic appearance of diseased mucosa is nonspecific, adequate bacteriological and histological assessment of biopsied tissue is essential to differentiate tuberculosis from other disorders that may simulate it. We stress the importance of microscopy and culture for Mycobacterium tuberculosis.

Nocturnal dosage regimen of sucralfate in maintenance treatment of gastric ulcer.

Sixty-six patients with recently healed gastric ulcers were entered into a double-blind, placebo-controlled, six-month maintenance trial to determine whether sucralfate 2 g at night reduces the liability to recurrent ulceration. Thirty-three patients were randomly assigned to treatment with sucralfate and 33 were assigned to placebo. Endoscopy was performed at the time of entry into the study and at 24 weeks, or earlier if clinical relapse occurred during this period. Of the patients available for analysis, endoscopic recurrences were found in eight of the 29 patients (28 percent) randomly assigned to sucralfate and in 15 of the 27 patients (56 percent) assigned to placebo. Eight of the recurrences noted at 24 weeks were asymptomatic and, of these, five were in the placebo-treated group. The cumulative relapse rate at 24 weeks was significantly lower in the sucralfate-treated group (p less than 0.05), and the Cox-Mantel text showed a significant difference between the cumulative relapse curves of the two treatment groups over the 24-week period (p less than 0.05). The results indicate that a single maintenance dose of sucralfate 2 g at night reduces the relapse rate in patients with recently healed gastric ulceration.

Giant hepatic hemangiomas: diagnostic and therapeutic dilemmas.

This report describes four cases of surgically treated giant hepatic hemangiomas which illustrate some diagnostic and therapeutic difficulties encountered in the management of this condition. An important diagnostic triad has emerged, which should alert the physician to the possibility of a complicated hepatic hemangioma: the clinical signs of an acute inflammatory liver process contrasted with a normal white blood cell count and liver function tests. Hemangiomas of the left lobe were either missed or poorly demonstrated on selective hepatic angiographic examination, and in two patients the diagnosis was made only at the time of laparotomy. Hepatic resection was successfully performed in all patients; there was minimal morbidity and none of the patients died. In two patients with multiple hemangiomas, only symptomatic or easily resectable lesions were removed. All patients are alive and well; three have been followed up for more than 5 years. We conclude that resection in asymptomatic cases should be carried out only in those cases that require a diagnostic laparotomy and in those where the lesion is easily resectable. The majority of patients with symptomatic and complicated tumors should undergo resection, but even in these patients continued conservative treatment is appropriate when the risk of major resection outweighs the small risk of live-threatening bleeding.

Periampullary cyst: a surgically remediable cause of pancreatitis.

We report two patients with periampullary cysts associated with recurrent attacks of acute pancreatitis. In both patients the diagnosis was made preoperatively by upper gastrointestinal endoscopy and ERCP, which was also useful in determining the relationship of the cysts to the biliary and pancreatic ductal systems. Simple marsupialisation of the cysts resulted in long term relief of symptoms. Congenital cystic anomalies in the second part of the duodenum should be diligently sought in patients with pancreatitis of unexplained cause, as surgical therapy is safe and effective.

Fibrinogen synthesis in the rat; role of the C terminal end of the gamma chain of fragment D1.

The terminal fibrinogen degradation product fragment D1 is known to regulate fibrinogen synthesis but the determinants in the D1 molecule responsible for this property are not known. The effect of fragment D1 on fibrinogen synthesis by the isolated perfused rat liver was studied using the (14C) carbonate method. Addition of 25 mg of fragment D1 to 100 ml of whole blood perfusate resulted in a significant increase in fibrinogen synthesis. When the C-terminal end of the gamma-chain of D1 was further plasmin-degraded to form fragment D3 this fibrinogen-enhancing effect was lost. Our studies suggest that the C-terminal of the gamma-chain of fragment D1 plays a role in regulating fibrinogen synthesis by the isolated rat liver.

A comparison of sucralfate dosage schedule in duodenal ulcer healing. Two grams twice a day versus one gram four times a day.

The conventional dosage schedule for sucralfate is 1 g 4 i.d., but a dose of 2 g 2 i.d. may be equally effective in duodenal ulcer healing. We compared the efficacy of these two regimens in duodenal ulcer healing. Seventy-seven patients with endoscopically proven duodenal ulceration were entered into a double-blind, controlled study and randomized to treatment with sucralfate 2 g 2 i.d. (on waking and at bedtime) or 1 g 4 i.d. (1/2 h before meals and at bedtime). The patients were endoscoped before entry into the study, after 4 weeks, and after 8 weeks if unhealed at 4 weeks. Of the patients considered suitable for analysis at 4 weeks, 79% (26/33) of those taking 2 g 2 i.d. had healed ulcers in comparison to 72% (23/32) of those taking 1 g 4 i.d. After 8 weeks, cumulative healing rates were 85% (28/33) and 80% (24/30), respectively. The results suggest that the more convenient dosage schedule of 2 g 2 i.d. is as effective as the 1 g 4 i.d. regimen in the short-term treatment of duodenal ulcer.

Cavernous haemangioma of the jejunum. A case report and approach to obscure chronic gastro-intestinal bleeding.

A 31-year-old woman who had been investigated for almost lifelong iron deficiency anaemia caused by chronic gastro-intestinal blood loss was found to have a large cavernous haemangioma of the jejunum. The literature relating to the latter is reviewed and a diagnostic approach to obscure gastro-intestinal bleeding considered.

Biochemical vitamin E deficiency in chronic pancreatitis.

In order to study the frequency of biochemical vitamin E deficiency in chronic alcohol-induced pancreatitis, we measured plasma vitamin E and total blood lipids in 44 patients with chronic pancreatitis and 83 control subjects (44 normal controls; 39 Crohn's disease controls). Mean plasma vitamin E and mean ratio vitamin E/total blood lipids, a more sensitive indicator of vitamin E status, were significantly lower in chronic pancreatitis when compared with either control group. A low vitamin E/total lipids ratio was found in 75% of patients with pancreatitis. Within the chronic pancreatitis group, mean plasma vitamin E and the ratio vitamin E to total lipids were significantly lower in those with steatorrhoea (23 patients--pancreatic steatorrhoea subgroup) than in those without (21 patients--pancreatic non-steatorrhoea subgroup). 91% of the pancreatic steatorrhoea subgroup had a low vitamin E/total lipids ratio. However, patients without pancreatic steatorrhoea also had significantly lower levels of plasma vitamin E and the ratio vitamin E/total lipids when compared to controls. We conclude that biochemical vitamin E deficiency is common in chronic alcohol-induced pancreatitis, particularly in patients with steatorrhoea, and that factors other than fat malabsorption may be responsible for vitamin E deficiency in pancreatic non-steatorrhoea.

Comparison of pirenzepine with cimetidine in duodenal ulcer disease. A short-term and maintenance study.

Sixty-seven patients with endoscopically proven duodenal ulceration were entered into a double-blind study and randomized to treatment with pirenzepine (PZ) (Gastrozepin; Boehringer Ingelheim) 50 mg twice daily or cimetidine (CM) (Tagamet; Smith Kline & French Laboratories) 400 mg twice daily, given 30 minutes before breakfast and supper. Patients underwent endoscopic examination before entry, at 4 weeks, and at 8 weeks if unhealed at 4 weeks. Once healing was achieved, 43 patients were entered into a single-blind maintenance study with either PZ 50 mg at night or CM 400 mg at night according to their original randomization. CM had a slight, but not significant, advantage over PZ after 4 weeks, but the 8-week data showed identical healing rates. The relapse rate appeared to be higher in the PZ-treated group, but this difference was also not significant. It is suggested that the evening dose of PZ be amended to 50 or perhaps 100 mg before bed in the short-term treatment of duodenal ulcer, and that a dose of 100 mg at night be considered for maintenance therapy in certain high-risk populations.

Diabetic diarrhoea and steatorrhoea. A case report and review of the literature.

A case of severe diabetic steatorrhoea is presented in a young Black male with poorly controlled diabetes, symptomatic peripheral neuropathy, evidence of autonomic neuropathy with gastroparesis and raised faecal fat excretion. A pancreatic function test was negative as were tests of small-bowel structure and function. There was resistance to all therapy. The literature on diabetic diarrhoea and steatorrhoea has been reviewed, and it is concluded that they are expressions of the same entity which remains a clinical problem for which there is at present no effective management.