Safety of endoscopical procedures during pregnancy.

INTRODUCTION: Data on safety issues and therapeutic outcomes of endoscopy in pregnancy remains limited especially in the local context. The concerns are that of safety in sedation and radiation to the foetus, effects on the pregnancy, the need for special precautions on mother and foetus during the procedure and long-term foetal outcome. We report a case series on four pregnant women to address these concerns and outline their therapeutic approaches. METHODS: We reviewed four patients who underwent oral gastroduodenoscopy (OGD) or endoscopic retrograde cholangiopancreatography (ERCP) during their pregnancies. Lead aprons were used to shield the foetuses in all patients that underwent ERCP. Sedation was given when necessary, and an anaesthetist was employed in one case for close patient monitoring. Fluoroscopy was minimised and radiographs were taken only when essential. RESULTS: The mean patient age was 27.8 years (range 23-35 years). The mean gestation was 21.5 weeks (range 14-32 weeks), with two patients each being in their second and third trimesters. The indications for ERCP were cholangitis and pancreatitis (one), choledocholithiasis on ultrasonography (two), and that for OGD was persistent vomiting (one). Two patients underwent sphincterotomy and one had a biliary stent inserted. One patient was lost to follow-up. The other three had a full-term normal delivery and all babies were healthy at birth with good birth weight and normal Apgar scores. CONCLUSION: Our series showed that endoscopic procedures in pregnancy are safe for both mother and foetus. However, these procedures should be restricted to cases with definite. indications and radiation exposure should be minimised with additional safety precautions such as minimal radiation exposure and the use of lead shield when applicable.

Endoscopic retrograde cholangiopancreatography in the elderly: outcomes, safety and complications.

INTRODUCTION: As the population ages, the incidence of biliary tract pathologies also increases, leading to an increase in the demand for endoscopic retrograde cholangiopancreatography (ERCP) interventions. Our aims are to assess the outcomes, safety and complications associated with ERCP performed in an elderly population. METHODS: Patients aged 80 years or over referred for ERCP from January 1999 to September 2002, were identified and retrospectively reviewed. RESULTS: 103 patients (68 females, mean age 84.6 +/- 3.9 years old) underwent 144 procedures (1-6 procedures/patient). The main indications were cholangitis (51.4 percent), choledocholithiasis (19.4 percent) and blocked stents (14.6 percent). Malignancies represented 5.6 percent of indications. The mean procedure time was 38 +/- 16 minutes. The overall success rate was 80.5 percent. Minor events occurred in 23 percent (tachycardia 13, desaturation six, transient hypotension six, self-limiting bleed four, extravasations three, and mild pancreatitis one). Major events were post sphincterotomy bleeding (five days post-procedure) one, duodenal perforation one (Billroth-II gastrectomy, survived after surgery), cholangitis two, and one death was probably procedure-related (acute myocardial event five days post-stenting in a patient with Klatskin tumour). Seven deaths occurred within one month of ERCP, due to advanced malignancies (four), sepsis (two) and acute myocardial infarction (one). Patients who died within one month had significantly higher serum urea (p-value equals 0.001), and creatinine (p-value equals 0.007) levels, and lower haemoglobin (p-value equals 0.014) level. More patients had an underlying malignancy (p-value less than 0.001). In addition, they were given significantly less conscious sedation (midazolam [p-value equals 0.002] and fentanyl [p-value equals 0.018]). CONCLUSION: Our study showed that ERCP is safe in an elderly Asian population. Minor complications are usually transient and related to sedation, and mortality is usually related to severity of illness and underlying malignancies.

Clinical usefulness of endoscopic ultrasonography with or without fine needle aspiration in the diagnosis and staging of pancreatic carcinoma.

INTRODUCTION: The aims of this study was to show the accuracy and clinical usefulness of endoscopic ultrasonography (EUS) with EUS-guided fine needle aspiration (FNA) in the diagnosis and staging of pancreatic cancer not obvious in computed tomographic (CT) scan abdomen imaging. MATERIALS AND METHODS: Five male patients were evaluated; 4 presented with obstructive jaundice and 1 had unexplained loss of weight. The mean age was 66 years (range, 40 to 77). All had CT scan abdomen imaging which did not show any obvious pancreatic tumour. EUS with FNA was done for all cases when indicated. Surgical findings, if any, were obtained and compared to EUS findings. RESULTS: EUS easily detected the pancreatic tumour in all 5 cases. The tumour sizes detected ranged from 27 to 40 mm in diameter. These corresponded fairly accurately with that of surgical findings for all 3 who had surgery. EUS reported 3 cases with pathological lymph node involvement. All 5 cases were confirmed by FNA or surgery. EUS was also accurate in 4 cases, which reported the absence of portal vein or superior mesenteric vein invasion. Surgical documentation could not verify the fifth case. There were no complications at all from the EUS with/without FNA. CONCLUSION: This case series showed that EUS with/without FNA appears to be useful and safe in diagnosing and staging pancreatic head tumours not detectable by CT scanning.

Clip-induced biliary stone.

Surgical clip migration is a well-known phenomenon ever since their first use in surgery. The mechanism of clip migration is poorly understood, and can occur from days to years after laparoscopic cholecystectomy. Migration of the surgical clips may be a complex process involving necrosis, pressure exerted from intra-abdominal movement, formation of stones over the exposed clip within the bile duct, and eventual migration into the common bile duct. We report two cases, a 58-year-old man and a 54-year-old woman, of clip- induced biliary stones resulting from surgical clip migration a few years after laparoscopic cholecystectomy.

Spontaneous choledochoduodenal fistula secondary to long-standing ulcer disease.

There are several varieties of bilioenteric fistulae. They are usually incidental findings, but once detected, various modalities can then be employed to further delineate the fistula. The fistulae usually arise as a complication of chronic duodenal ulcer disease, cholelithiasis or previous instrumentation to the biliary system. The presence of a fistula per se does not immediately equate to necessity for surgery. The treatment is dependent on its aetiology.

Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction.

BACKGROUND: The endoscopically placed enteral stent has emerged as a reasonable alternative to palliative surgery for malignant intestinal obstruction. This is a report of our experience with the use of enteral stents for nonesophageal malignant upper GI obstruction. METHODS: Data on all patients who had undergone enteral stent placement were reviewed. Those with a diagnosis of pancreatic cancer were compared with another similar cohort of patients who underwent palliative gastrojejunostomy. RESULTS: Thirty-one procedures were performed on 29 patients (mean age 67.7 years). Thirteen (45%) were men and 16 (55%) women. The diagnoses were gastric (13.8%), duodenal (10.3%), pancreatic (41.4%), metastatic (27.6%), and other malignancies (6.9%). Malignant obstruction occurred at the pylorus (20.7%), first part of duodenum (37.9%), second part of duodenum (27.6%), third part of duodenum (3.5%), and anastomotic sites (10.3%). Twenty-nine (93.5%) procedures were successful and good clinical outcome was achieved in 25 (80.6%). Re-obstruction by tumor ingrowth occurred in 2 patients after a mean of 183 days. The median survival time for patients with pancreatic cancer who underwent enteral stent placement compared with those who underwent surgical gastrojejunostomy was 94 and 92 days, charges were $9921 and $28,173, and duration of hospitalization was 4 and 14 days, respectively (latter 2 differences with p value < 0.005). CONCLUSION: Endoscopic enteral stent placement of nonesophageal malignant upper GI obstruction is a safe, efficacious, and cost-effective procedure with good clinical outcome, lower charges, and shorter hospitalization period than the surgical alternative.

Gastrointestinal stromal sarcoma--a case report of palliative enteral stenting.

We report a case of metastatic gastrointestinal stromal sarcoma (GISS) in a 33-year-old man who subsequently underwent successful palliative endoscopically-placed enteral stenting for duodenal stenosis secondary to extrinsic compression. Enteral stenting for palliative relief of malignant gastrointestinal obstruction is recommended for its safety, efficacy and cost-effectiveness.

An unusual manifestation of severe caustic injury.

Knowledge of the sequelae of caustic ingestion is of relevance to staff of the Emergency Room, Intensive Care Unit, surgical and gastroenterology services. It poses a considerable management problem and may result in life-threatening complications such as visceral perforation. This case report demonstrates an unusual and previously unreported manifestation of caustic injury.

Pancreatic duct stents for "obstructive type" pain in pancreatic malignancy.

OBJECTIVE: Obstruction of the main pancreatic duct from malignancy with secondary ductal hypertension may be an important contributor to pain. The aim of our study was to determine the efficacy and safety of pancreatic stent placement for patients with "obstructive" pain due to pancreatic malignancy. METHODS: Pancreatic duct stents were placed in 10 consecutive patients with malignant pancreatic duct obstruction and abdominal pain. Seven patients had "obstructive" type pain and three had chronic unremitting pain. Nine had primary pancreatic ductal adenocarcinoma and one had metastatic melanoma. There were eight women and two men. Mean age was 61 yr (range, 47-80 yr). All patients had dominant main pancreatic duct strictures with proximal dilation. Tumors were unresectable. All patients took potent analgesics before endoscopic stent therapy. Polyethylene pancreatic stents, 5- and 7-French, were successfully placed in seven patients, and self-expanding metallic stents were successfully placed in three patients. RESULTS: There were no procedure-related complications. One patient required a single repeat examination to replace a migrated stent. Seven patients (75%) experienced a reduction in pain. Analgesia was no longer required in five (50%). Three patients who did not improve had chronic pain rather than "obstructive" pain. CONCLUSIONS: Pancreatic stent placement for patients with "obstructive" pain secondary to a malignant pancreatic duct stricture appears to be safe and effective. It should be considered as a therapeutic option in these patients. It does not seem to be effective for chronic unremitting pain.

An audit of percutaneous endoscopic gastrostomy in a general hospital in Singapore.

OBJECTIVE: We conducted an audit on 50 percutaneous endoscopic gastrostomies (PEGs) performed by physician endoscopists from January 1996 up to November 1997. DESIGN: A retrospective cohort study was conducted. RESULTS: The mean age of the patients was 68.5 years (range 20-101) and the main indications were cerebrovascular accident in 40 (80%), neurological dysphagia in six (12%) and head injury in three (6%). The interval between the diagnosis of dysphagia and PEG was > 60 days in 19 patients (38%), 31-60 days in eight (16%) and < or = 30 days in 23 (46%). The commonest reason for PEG insertion was intolerance to nasogastric tube in 49 patients (98%). Twelve patients had antibiotics given concurrently for other infections and two had antibiotics given specifically to cover PEG insertion. There was evidence of post-PEG infection in two of 14 patients given antibiotics (14%) and in 14 of 36 patients not given antibiotics (39%). By Cox regression, the adjusted relative risk of infection in patients receiving antibiotics versus those not receiving was 0.6927 (95% CI 0.3396-1.4130; not significant). The 30-day mortality was 7/48 patients (15%), with two patients lost to follow-up before 30 days. There were no deaths directly attributable to PEG. CONCLUSIONS: PEG is still not adequately requested by doctors for patients needing enteral feeding for more than 30 days. The use of antibiotics in this retrospective cohort study failed to show any benefit in reducing the rate of infective complications.

Weils' syndrome and concomitant hepatitis B infection.

Leptospirosis is a ubiquitous, spirochetal zoonosis which presents with a broad clinical spectrum. Weil's syndrome, characterised by jaundice, renal failure and bleeding manifestations is the most severe form. A high index of suspicion for the diagnosis is required to institute therapy promptly. We describe a case of serologically confirmed Weil's syndrome with concomitant hepatitis B infection.

Ticlopidine induced cholestatic jaundice.

Ticlopidine hydrochloride (Ticlid) has been increasingly used as an antiplatelet agent. Some studies showed that it has higher efficacy in reducing stroke recurrence when compared to conventional aspirin. Side effects like gastrointestinal disturbances and blood dyscrasias are common but ticlopidine-induced cholestatic jaundice has been reported only rarely. We present a case report on a patient who has ticlopidine-induced cholestatic jaundice.