Omeprazole use at an urban county teaching hospital.

To determine the appropriateness of use of omeprazole, all outpatient prescriptions over one year from a single county hospital pharmacy were analyzed. Appropriateness of omeprazole use was assessed by literature review and expert opinion. Two hundred twenty-one prescriptions were evaluated; 112 (56%) were inappropriate. Women received more inappropriate prescriptions (61% vs 44%, p = 0.01) and received endoscopy less frequently (52% vs 71%, p < 0.02) than did men. When age, gender, and prescribing clinic were examined as predictors of inappropriate use, only gender was significant (OR = 2.01, 95% CI = 1.52-2.66). This study, from a single institution, showed a high rate of inappropriate omeprazole use.

Fluoroscopy is not necessary for Maloney dilation of chronic esophageal strictures.

The use of fluoroscopic guidance for Maloney dilation is controversial. In order to determine if fluoroscopic analysis would enhance the success of dilation and increase recognition of adverse events, we prospectively studied 125 Maloney dilations in 80 patients (mean age, 69.3 years) with mild esophageal strictures. Most strictures (89%) resulted from acid-peptic disease. Operators included two staff physicians (5 and 25 years of experience) and one trainee (1 year of experience). Dilations were performed with the patient seated upright and the operator noting the presence and amount of resistance (dilator size, 36F to 60F; median, 50F). The fluoroscopic monitor was not visible to the operator, and the results were recorded by an observer who did not communicate with the operator. Operator assessment of Maloney dilation was correct in 122 of 125 procedures. Two failures were interpreted as no passage by the operator when passage had occurred as confirmed by fluoroscopy. One failure was interpreted as passage when no passage had occurred as indicated by fluoroscopy. Adverse events included 1 episode of tracheal intubation and failure to recognize the dilator tip curling in the esophagus as observed by fluoroscopy in 6 of 125 (4.8%) procedures. Operator assessment of resistance was more often associated with curling of the dilator on the greater curve of the stomach than with an esophageal stricture. Greater operator experience tended to correlate with increased success and correct interpretation of dilation. Maloney dilations performed with patients at 30 degrees rather than upright at 90 degrees were associated with a marked increase in unsuccessful dilator passage and curling of dilator tip.(ABSTRACT TRUNCATED AT 250 WORDS)

The non-bleeding visible vessel versus the sentinel clot: natural history and risk of rebleeding.

Non-bleeding visible vessel and sentinel clot are terms used interchangeably to describe protuberances in the base of ulcers that have recently bled, but a consensus as to their definition or natural history does not exist. In patients with severe ulcer hemorrhage, non-bleeding protuberances were classified as vessels, with or without a small attached clot, or as sentinel clots, according to a schema based on the appearance of the protuberance at endoscopy but not subjected to pathologic correlation. Endoscopic therapy was not performed at the index endoscopic evaluation, and natural evolution was prospectively documented with daily videoendoscopy. Eleven (46%) of 24 patients with non-bleeding protuberances had rebleeding. Independent classification by three authors concurred in 18 (75%) of 24 lesions. Ten (91%) of 11 vessels with or without attached clot rebled versus 0 (0%) of 7 sentinel clots and 1 (17%) of 6 lesions without unanimous classification (p < 0.01, vessels versus other groups). Rebleeding occurred in 5 (71%) of 7 nonpigmented (pale or white), 6 (38%) of 16 red or purple, and 0 (0%) of 1 black protuberances. In general, vessels persisted until rebleeding, whereas sentinel clots disappeared within 1 to 3 days. We conclude that nonbleeding protuberances in ulcer bases can be separated into vessels, which have a high risk of rebleeding, and sentinel clots, which have a low risk of rebleeding.

Objective evaluation of endoscopy skills during training.

OBJECTIVE: To evaluate the number of supervised gastrointestinal endoscopic procedures required to achieve initial competency using a simple objective grading system. DESIGN: Prospective, cross-sectional study. SETTING: A gastroenterology and surgical training program at a large, university-affiliated county hospital. PARTICIPANTS: Seven gastroenterology fellows and five fourth-year surgery residents. INTERVENTIONS: Trainees were graded postprocedure using a microcomputer program. Grading criteria for esophagogastroduodenoscopy included entering the esophagus (esophageal intubation), traversing the pylorus into the duodenum, and recognizing whether the upper gastrointestinal tract was abnormal. Criteria for colonoscopy were traversing the splenic flexure, intubating the cecum, and recognizing whether the colon was abnormal. RESULTS: When presented with a case mix representative of practice, esophageal intubation did not reach 90% until more than 100 procedures had been done. Cecal intubation remained at only 84% after 100 procedures. CONCLUSIONS: More than 100 supervised upper gastrointestinal endoscopies or colonoscopies are necessary to achieve technical competence in gastrointestinal endoscopy.

Comparative surgical and colonoscopic appearance of colon anastomoses constructed with sutures, staples, and the biofragmentable anastomotic ring.

UNLABELLED: The following animal study was undertaken to compare and assess the endoscopic gross appearance and histology of colonic anastomoses constructed with sutures, staples, and the biofragmentable anastomotic ring (BAR). METHODS: Three anastomoses--1 BAR, 1 stapled, and 1 sutured--were placed in each of 48 dogs and colonoscopy and anastomotic evaluation were done. RESULTS: No leaks were found by air insufflation at surgery. Grossly, the BAR had serosal hematomas in 27/48 anastomoses vs 7/48 for stapled and 1/48 for sutured (BAR vs stapled P < 0.0005 and sutured vs stapled P = 0.07). Adhesions were significantly greater for BAR (35/36) and sutured (34/36) compared to stapled (26/36) (BAR vs stapled P = 0.01 and sutured vs. stapled P = 0.04). Colonoscopic exams at days 3, 7, and 28 showed no significant difference among groups with respect to bleeding, ulceration, necrosis, granulation, or contour. Sutured anastomoses were more stenotic (24/31) than stapled (4/31) or BAR (3/31) ones (BAR vs sutured and sutured vs stapled P < 0.005). At 28 days, 10/10 sutured vs 2/10 stapled vs 3/10 BAR were stenotic (BAR vs sutured P = 0.02, sutured vs stapled P = 0.01). Inflammation on histologic exam at 28 days was not significantly different: sutured (12/12), stapled (12/12), or BAR (9/12). Fibrosis was more prominent in sutured (12/12) than in stapled (5/12) or BAR (4/12) anastomoses (BAR vs sutured P = 0.001, sutured vs stapled P = 0.004, and BAR vs stapled P = 1.00). All anastomoses healed primarily without necrosis or obstruction. CONCLUSIONS: (1) Colonoscopy to evaluate anastomoses can be done safely even in the early post-operative period. (2) The BAR anastomoses had the most serosal hematomas; BAR and sutured had more adhesions than stapled anastomoses; and sutured anastomoses had the most stenosis and fibrosis. None of these differences was of clinical significance.

Colonic mucosal ecchymoses after extracorporeal shock wave lithotripsy for upper ureteral calculus.

Bright red blood was found in stool immediately following extracorporeal shock wave lithotripsy with 2,700 shock waves to a right upper ureteral calculus beside an indwelling Double-J stent. The vital signs remained stable and bleeding did not recur. Colonoscopy revealed small areas of mucosal ecchymoses in the ascending colon. To our knowledge this effect of extracorporeal shock wave lithotripsy has not been reported previously. There is no evidence as yet that these ecchymoses are of any clinical significance for most patients.

The effects of methylprednisolone on postoperative bowel motility and propulsion in dogs.

Eighteen mongrel dogs underwent handsewn right segmental colectomy. One group was pretreated with methylprednisolone 30 mg/kg intravenously at the time of surgery and 7.5 mg/kg intravenously at 6-hour intervals for 24 hours; the second group served as a saline control. Motility was measured postoperatively by manometric catheters, and propulsion was measured by x-ray evidence of passage of radiopaque markers. Marker studies showed more rapid passage in animals pretreated with steroids, but differences were not statistically significant (P = 0.11). Motility studies showed a significant overall increase in motility in steroid-treated animals on the first postoperative day (P = 0.03); smaller differences on the second or third days were not significant. Motility studies comparing ileum, cecum, and sigmoid showed the ileum to be the site of significant steroid effect (P = 0.02), with insignificant benefit seen in the colon. The data suggest that methylprednisolone may be of some objective benefit in restoration of postoperative bowel motility, and the site of action may be in the small bowel and not at the anastomosis.

Porta-caval shunting changes neuronal sensitivity to ammonia.

The relations between an effect of ammonia on postsynaptic inhibition, the amount of ammonium acetate i.v. to obtain this effect, and the tissue concentrations of NH4+ and glutamine were investigated in the cerebral cortex of cats without and with portacaval shunts. Normal cats required 2.43 mmol/kg ammonium acetate to affect postsynaptic inhibition. Cerebral NH4+ and glutamine increased from 0.21 mumol/g to 0.77 mumol/g and from 2.92 mumol/g to 5.54 mumol/g, respectively. In portacaval shunted cats, postsynaptic inhibition was normal in spite of increases of NH4+ and glutamine to 1.37 mumol/g and 14.28 mumol/g, respectively. Only 0.7 mmol/kg of ammonium acetate were sufficient to affect postsynaptic inhibition. This was associated with a statistically insignificant increase of NH4+ to 1.61 mumol/g and no change of glutamine. A chronic portasystemic shunt markedly increases the tolerance of postsynaptic inhibition to NH4+. However, postsynaptic inhibition becomes very sensitive to an acute systemic ammonia load and the associated increase of tissue NH4+ in the cerebral cortex. These observations help to understand the pathogenesis of the encephalopathy precipitated in patients with portasystemic shunts by an acute systemic ammonia load such as resulting from a gastrointestinal hemorrhage.

Changes in the surgical treatment of acid peptic disease.

The surgical treatment of acid peptic disease at Hennpin County Medical Center (Minneapolis, MN) during two time periods separated by a 12-year interval was reviewed. In comparing the more recent period with the earlier, the following was observed: 1) total number of operations decreased by one-third, but the number of emergency operations was the same; 2) overall operative mortality did not change even though more patients in the recent period had associated systemic disease; 3) the location of ulcers did not change; 4) hemorrhage, as an indication for emergency surgery, increased both relatively and absolutely; and 5) the preferred surgical procedure during both periods was vagotomy and antrectomy, but vagotomy and drainage was done with increased frequency in the more recent period. During both time periods, emergency surgery was associated with almost a tenfold increase in operative mortality.

Management of pancreatic pseudocysts.

Fifty-five patients with pancreatic pseudocysts were evaluated over a ten year period and most of these cysts were diagnosed over the last five years with the aid of CT scans, ultrasound and ERCP. Among 39 patients who underwent surgical treatment, ultrasound was correct in 17 of 20 (10 per cent) and falsely positive in one patient out of 20 patients (5 per cent). The CT scan was correct in 12 of 13 patients (92 per cent) and falsely positive in one patient out of 13 patients (8 per cent). ERCP was correct in ten of 12 patients (83 per cent) with one false-negative (8 per cent) and one indeterminate (8 per cent) result. The mortality for 39 surgical patients was 21 per cent and most deaths were because of sepsis. Among 15 patients who did not undergo operative treatment, five had pseudocysts greater than 4 centimeters in diameter and only one patient had clinical regression of the pseudocyst. Ten of the 15 patients had pseudocysts less than 4 centimeters and nine of these patients had clinical regression of the pseudocysts. The results of the data suggest that pseudocysts 4 centimeter in size or smaller may be safely observed by serial CT examination or ultrasound.

Cimetidine dynamics after repeated intravenous injection.

Cimetidine dynamics were studied in six multiple-trauma patients receiving 300 to 600 mg every 6 hr for prevention of stress ulceration. Patients received cimetidine intravenously for a mean duration of 7.8 days. There was a positive correlation between cimetidine serum concentration and gastric pH; the correlation between intragastric cimetidine concentration and gastric pH was stronger. The association between therapeutic efficacy (pH greater than 4) and serum concentration over 1 mcg/ml was significant. The association with gastric cimetidine concentration above 2 mcg/ml was significant.

Aminopyrine breath test predicts surgical risk for patients with liver disease.

To determine whether the [14C] aminopyrine breath test (ABT) predicts surgical risk in patients with liver disease, it was obtained prior to various surgeries in 38 patients with known or suspected liver disease. A modified Child's classification was also determined. Six of the seven operative deaths (three Child's A, two B, two C) had ABTs less than 2.3%, while 30 of 31 survivors (24 Child's A, seven B) had ABTs greater than 2.3% (p less than 0.000018). Seven of the 16 patients with normal ABTs had biopsy-proven cirrhosis and had postoperative courses indistinguishable from the remainder of the group. We conclude that surgery in patients with ABTs less than 2.3% is associated with extremely high mortality. In addition, cirrhotics with normal ABTs tolerate elective surgery well.

Ammonia and methionine sulfoximine intoxication.

Intoxication with ammonium acetate abolished the suppression of action potential generation by cortical postsynaptic inhibition, i.e. produced 'disinhibition', due to the inactivation of neuronal Cl- extrusion. With the occurrence of disinhibition cerebral ammonia increased to 445% of normal; glutamine increased to 170%. Methionine sulfoximine (MSO), an inhibitor of glutamine synthetase, produced disinhibition about 3 h after administration; at this time cerebral ammonia was increased to 290% of normal, glutamine was unchanged. Intoxication with MSO for less than 3 h significantly decreased the amount of ammonium acetate needed to produce disinhibition at cerebral ammonia concentrations ot 340-430% of normal. MSO produces an endogenous ammonia intoxication which: (i) decreases the amount of exogenous ammonia required to affect cortical postsynaptic inhibitions; and (ii) eventually becomes sufficiently severe to disturb cortical inhibitory neuronal interactions by itself.

The value of operative cholangiography.

A retrospective review was made of the records of 152 patients undergoing cholangiography at the time of cholecystectomy. Of the 152 cholangiograms, 65 revealed major technical deficiencies. In spite of this, the use of cholangiography allowed 31 patients with classical indications to be spared common duct exploration. Furthermore, the procedure detected unsuspected common duct stones in nine patients. As a result of these findings, we recommend the use of cystic duct cholangiography routinely in patients undergoing cholecystectomy.

Hepatic veno-occlusive disease caused by 6-thioguanine.

Clinically reversible veno-occlusive disease of the liver developed in a 23-year-old man with acute lymphocytic leukemia after 10 months of maintenance therapy with 6-thioguanine. Serial liver biopsies showed the development and resolution of intense sinusoidal engorgement. Although this disease was clinically reversible, some subintimal fibrosis about the terminal hepatic veins persisted. This case presented a unique opportunity to observe the histologic features of clinically reversible hepatic veno-occlusive disease over time, and may be the first case of veno-occlusive related solely to 6-thioguanine.

Cimetidine dynamics after single intravenous doses.

Cimetidine dynamics were studied in nine multiple-trauma patients. Mean elimination half-life was 2.27 hr, mean volume of the central compartment was 0.29 l/kg, mean volume at steady state averaged 0.90 l/kg, and mean total body clearance was 9.02 ml/min/kg. After intravenous cimetidine, drug concentrated in gastric fluid reached a peak concentration in 3 hr. Gastric plasma cimetidine ratios after equilibration ranged between 3.0 and 4.3. There was a correlation between cimetidine gastric juice concentration and gastric pH (r = 0.50), but no correlation was found between plasma cimetidine concentration and pH (r = 0.13).

The relationship of hemorrhoids to portal hypertension.

Records of 188 patients with documented portal hypertension were reviewed to determine the incidence of hemorrhoids as well as bleeding complications associated with this condition. The incidence of hemorrhoids among these patients was not increased compared to the normal population. Six of the patients with portal hypertension did, however, bleed massively from hemorrhoids. Elevated portal venous pressure is an important factor in those patients having severe hemorrhoidal bleeding. The presence of coagulation defects may also be of considerable importance.