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.

Breast carcinoma metastatic to the esophagus: clinicopathological and management features of four cases, and literature review.

Dysphagia due to esophageal metastases from primary breast carcinoma is an unusual entity. In this series of cases, we describe the clinical features of dysphagia due to metastatic esophageal lesions in four patients (with a primary diagnosis of breast cancer made 8-22 yr previously). We provide the first endoscopic ultrasound characterization of metastatic lesions to the esophagus from breast carcinoma. Endoscopic management of these strictures with both bougienage and balloon dilation techniques resulted in esophageal perforation in three of our four patients. We believe that endoscopic ultrasound is helpful in the diagnosis of metastatic breast cancer to the esophagus. However, endoscopic dilation of these strictures should be done gently and only after other treatment options have been carefully considered.

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.

Papillotomy and functional disorders of the sphincter of Oddi.

The term "functional" as applied to disorders of the sphincter of Oddi is indefinite since it encompasses a spectrum of disorders from histopathologic fibrosis of the sphincter to sphincteric dysfunction without evident pathologic transformation. Although there are several approaches to the diagnosis of sphincter of Oddi dysfunction, the diagnosis still depends on the exclusion of other causes of obstruction. Reports of surgical sphincteroplasty in patients with this diagnosis suggest that the outcome is unpredictable. Operative mortality ranges from 0.6% to 6.0% and morbidity from 3.3% to 18%. Operative sphincteroplasty appears to have no adverse sequelae long-term, although there are few reports of extended follow-up. In our experience, about 10% of patients undergoing endoscopic sphincterotomy for calculi have recurrent biliary problems during extended follow-up, but most problems were not formidable. In large series of patients undergoing endoscopic sphincterotomy, papillary stenosis is the indication for the procedure in about 5% of cases. With this indication, immediate complications occur with greater frequency compared to endoscopic sphincterotomy for choledocholithiasis. The validity of every proposed test for sphincter dysfunction and/or stenosis has been challenged, and the diagnosis must still be considered imprecise. This fundamental problem makes it difficult to interpret the results of endoscopic sphincterotomy. It also necessitates a cautious approach to management of this disorder by endoscopic sphincterotomy. Other methods of sphincter manipulation such as endoscopic balloon dilation have not been studied extensively. Although endoscopic sphincterotomy has been performed in a few patients with idiopathic recurrent pancreatitis, the procedure must be considered experimental in this group of patients.

Free cytosolic calcium and secretagogue-stimulated initial pancreatic exocrine secretion.

In order to establish the role of secretagogue-induced changes in free cytosolic Ca2+ ([Ca2+]i) in pancreatic enzyme secretion, we measured the effects of carbachol, cholecystokinin-octapeptide (CCK-OP), bombesin, substance P, and bromo-A23187 on amylase release and [Ca2+]i in guinea pig pancreatic acini loaded with the Ca2+-selective fluorescent indicator, fura-2. Evaluation of time courses and dose-response curves indicated that carbachol, CCK-OP, bombesin, and substance P cause extracellular Ca2+-independent transient increases in [Ca2+]i and transient bursts in amylase release (initial secretion). The potencies for the secretagogues to increase [Ca2+]i and initial amylase release were similar. Bromo-A23187 also caused an extracellular Ca2+-independent transient increase in [Ca2+]i and amylase release. In the absence of extracellular Ca2+, sequential additions of substance P followed by carbachol caused transient increases in [Ca2+]i correlating with transient bursts in amylase release. In contrast, in acini first treated with carbachol, the ability of substance P to increase [Ca2+]i and amylase release was blocked. Sustained secretion caused by the secretagogues was dependent on extracellular Ca2+ but occurred at basal [Ca2+]i. Increasing [Ca2+]i during the sustained phase of stimulation by increasing the extracellular Ca2+ concentration or with bromo-A23187 did not increase the rate of sustained secretion.