Defining a role for endoscopic ultrasound in staging periampullary tumors.

BACKGROUND: The goal of the preoperative workup in patients with suspected periampullary carcinoma is to establish the diagnosis with a high degree of certainty. In this study we compared endoscopic ultrasonography (EUS) and computed tomography (CT) scans for the detection of tumor, lymph node metastasis, and vascular invasion in patients with suspected periampullary carcinoma in order to define a role for EUS in the preoperative staging of these patients. METHODS: Thirty-seven consecutive patients received EUS and CT scanning followed by operation for presumed periampullary carcinoma during a 30-month period. Both imaging modalities were reviewed in a blinded fashion and the results compared with pathology and operative reports on all patients. RESULTS: Sensitivity, specificity, positive predictive value, and negative predictive value for tumor detection by EUS were 97%, 33%, 94%, and 50%, respectively, compared with 82%, 66%, 97%, and 25% for CT scan. For lymph nodes the values were 21%, 80%, 57%, and 44%, respectively, for EUS compared with 42%, 73%, 67%, and 50% for CT. For vascular invasion, the values were 20%, 100%, 100%, and 89%, respectively, for EUS, compared with 80%, 87%, 44%, and 96% for CT. CONCLUSIONS: CT is the initial study of choice in patients with suspected periampullary tumors. EUS is superior for detecting tumor and for predicting vascular invasion. Therefore, EUS should be used for patients in whom CT does not detect a mass and for those with an identifiable mass on CT in whom vascular invasion cannot be ruled out.

Effect of dietary oat and soy fiber on bowel function and clinical tolerance in a tube feeding dependent population.

OBJECTIVE: The role of fiber in tube feeding products has not clearly been defined. While some studies suggest that fiber can increase stool weight and bowel transit time in acutely ill patients, there is less information in stable patients receiving chronic enteral nutritional support. DESIGN: Using a crossover study design, we investigated the effect of 28.8 g/day of a 50% soy and 50% oat fiber combination in 10 medically stable residents of a chronic care facility. Subjects were randomized to initially receive 10 days of either Isocal HN or Ultracal, which are identical in composition except Ultracal contains 14.4 g/L of fiber. After the first 10-day study, subjects underwent a washout followed by a second 10-day study using the other product. Fecal dye markers were used to identify appropriate collection times. RESULTS: Fiber significantly increased the number of bowel movements per day (0.9 +/- 0.4 vs 0.5 +/- 0.2, p < 0.05) and fecal weights (57 +/- 31 vs 32 +/- 25 g/day, p < 0.05). Fiber also caused a significant increase in fecal nitrogen output (110 +/- 65 vs 75 +/- 74 mg/day, p < 0.05) and fecal energy (141 +/- 73 vs 76 +/- 62 kcal/day, p < 0.05). Fiber did not affect fecal moisture, gastric emptying, or intestinal transit time. CONCLUSION: We conclude that the addition of a combination of soy and oat fiber to tube feeding material is well tolerated, and promotes regular bowel movements without altering the rate of gastric emptying or intestinal transit time.

Oral Candida colonizes the stomach and gastrostomy feeding tubes.

The lumen of gastrostomy tubes is frequently colonized with Candida. To investigate the source of this contamination, 20 consecutive malnourished patients undergoing placement of a percutaneous endoscopic gastrostomy tube and ten ambulatory controls having routine upper endoscopy performed had both their oral cavity and gastric antrum swabbed and cultured. Percutaneous endoscopic gastrostomy tube recipients who after several weeks were still under our care (9 of 20) had the lumen of their tubes cultured. Fungi were isolated from the stomach in 13 (65%) of 20 patients undergoing percutaneous endoscopic gastrostomy tube placement but in only 1 of 10 ambulatory patients (p < .01). The species isolated from the oral cavity, the stomach, and later the gastrostomy tube were identical in most cases. We conclude that gastrostomy tubes are probably colonized by oral organisms that have made their way into the stomach.

Intraluminal fungal colonization of gastrostomy tubes.

Percutaneous endoscopic gastrostomy tubes are frequently colonized with fungal and bacterial organisms. This has not been previously reported. In our sample of 10 patients, nine percutaneous endoscopic gastrostomy tubes were colonized with fungi. This occurred as early as 1 week after placement. Candida tropicalis was isolated in five patients. It is hypothesized that a variety of fungi use components of the gastrostomy tube polymer, such as polymer additives, which contribute to the structural deterioration of the tube.

Steroidogenesis of cultured granulosa cells in women at risk for ovarian hyperstimulation syndrome.

OBJECTIVE: To determine if cultured human granulosa cells (GCs) obtained from women at risk for ovarian hyperstimulation syndrome (OHSS) possess altered steroidogenic capacity. DESIGN: Prospective analysis of 28 consecutive in vitro fertilization-gamete intrafallopian transfer (IVF-GIFT) cycles. SETTING: In Vitro Fertilization Program at Rush Presbyterian St. Luke's Medical Center in Chicago, Illinois. PATIENTS: Eighteen patients (group I) with serum estradiol (E2) levels > 7,342 pmol/L on the day of exogenous human chorionic gonadotropin (hCG) administration (day 0) with > 10 ovarian follicles present (high risk for OHSS); 10 patients (group II) with E2 < or = 7,342 pmol/L on day 0 and < or = 10 follicles. INTERVENTIONS: Human GCs obtained during gonadotropin-releasing hormone agonist-pretreated IVF-GIFT cycles were cultured in the absence (control) or presence (hCG) of hCG, 1 IU/mL, and/or androstenedione (A) 10(-7) M. Granulosa cells obtained from follicles < or = 15 mm diameter were cultured separately from those obtained from follicles > 15 mm diameter. MAIN OUTCOME MEASURES: Estradiol (E2) and progesterone were measured in tissue-culture medium by a solid-phase direct radioimmunoassay. RESULTS: In vitro E2 production by cultured GCs was significantly increased in follicles < or = 15 mm diameter from women considered at risk of developing OHSS (group I). Estradiol response to hCG and/or A appeared enhanced in all follicles in group I. Progesterone production in the basal and hCG challenged state was greater in cells obtained from large follicles in group I than in group II. CONCLUSION: Ovarian hyperstimulation syndrome appears to be a function of an increased number of follicles that express an enhanced steroidogenic capacity.

Luteal phase support and severe ovarian hyperstimulation syndrome.

The incidence and statistical associations of the ovarian hyperstimulation syndrome (OHSS) were studied in 304 egg retrievals with gonadotrophin-releasing hormone agonist suppression, gonadotrophin administration and follicular aspiration. In addition to preserving corpus luteum function, the luteal phase administration of human chorionic gonadotrophin (HCG) was associated with a higher incidence of severe OHSS than was supplementation with progesterone alone (12 versus 0%, P less than 0.001). Severe OHSS occurred in 3.7% and 12% of retrievals without and with pregnancy respectively (P less than 0.01). Stepwise logistic regression showed that the occurrence of moderate or severe OHSS was statistically predicted by the log of the serum oestradiol on the day the initial HCG was given (P less than 0.0001), treatment with luteal phase HCG (P less than 0.0003), and fetal number (P less than 0.0079). In the late luteal phase of cycles without luteal HCG, the serum oestradiol concentration was one-tenth and the serum progesterone concentration was one-fifth of the luteal phase value with HCG support (P less than 0.001). Without luteal phase HCG, oestradiol was two-fold higher (P less than 0.001) and progesterone was 1.4-fold higher (P less than 0.005) in pregnant than in non-pregnant women. With luteal phase HCG, oestradiol was 1.4-fold higher in pregnant than in non-pregnant women (P less than 0.05), and progesterone was 1.7-fold higher (P less than 0.001). Oestradiol upper limits of 4400 and 14,700 pmol/l (1200 and 4000 pg/ml) for cycles with and without luteal phase HCG respectively correspond to approximately 5% risk of moderate or severe OHSS with a singleton pregnancy under these conditions.

Serum and follicular fluid (FF) estradiol (E2) levels in ovarian hyperstimulation syndrome (OHSS) during in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT) conception cycles after pituitary suppression.

Initial hope that ovarian hyperstimulation syndrome (OHSS) would be less likely to occur after pituitary suppression with gonadotropin releasing-hormone agonists (GnRH-a) has not been substantiated. GnRH-a/human menopausal gonadotropin (hMG) protocols often lead to OHSS with markedly elevated circulating estradiol (E2) levels in susceptible patients. This study was undertaken to determine whether or not intrafollicular E2 secretion is increased in these cases. Fifty-two in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT) conception cycles treated with GnRH-a/hMG were included in the study. GnRH-a, leuprolide, 0.5 mg, was administered subcutaneously from day 20 of the preceding cycle and the ovaries were stimulated with hMG, 75-225 IU bid intramuscularly, followed by human chorionic gonadotropin (hCG), 5000 IU. Twenty cycles (Group I) were associated with moderate or severe OHSS and 32 cycles (Group II) did not result in OHSS. E2 was measured in the serum on the day of hCG (day 0), on the day of oocyte retrieval (day 2), and at midluteal phase (days 6-8), as well as in the follicular fluid (FF) using a solid-phase direct RIA. Mean serum E2 was significantly higher at all three sampling times in Group I (OHSS) than in Group II. Both the number of follicles and the number of oocytes were also significantly higher in Group I.(ABSTRACT TRUNCATED AT 250 WORDS)