PubMed Health⌕ Search

Biomedical subjects

J B Marshall

Publications and source records attributed to J B Marshall.

At least 37 records · Page 2Linked to original sources
PubMed1996

Use of a pediatric colonoscope improves the success of total colonoscopy in selected adult patients.

BACKGROUND: Colonoscopy using a standard adult colonoscope can be difficult or impossible when there is a fixed, angulated sigmoid colon or stricture. It is sometimes possible to traverse such segments using a smaller-diameter, more flexible pediatric colonoscope. METHODS: For this prospective study, one endoscopist started 645 consecutive, elective colonoscopies with a standard adult Olympus CF-100L colonoscope (52% women, 48% men). There were 36 examinations (5.6%) in which the adult colonoscope could not be passed through a fixed, angulated sigmoid colon (n = 34) or a sigmoid colonic stricture (n = 2). In such instances (33 women and 3 men), the endoscopist switched to a pediatric colonoscope. RESULTS: The pediatric colonoscope successfully reached the cecum in 21 of the 36 cases (58.3%). The figure was 38.5% for the older Olympus CF-P20L fiberoptic colonoscope (n = 13) and 69.6% for the newer Olympus PCF-100 videocolonoscope (n = 23). Concomitant conditions in the 34 patients in whom the pediatric colonoscope was used because of a fixed, angulated sigmoid included previous pelvic surgery in 22, pelvic radiation therapy in 2, pelvic endometriosis in 3, and two with previous sigmoid diverticulitis. CONCLUSIONS: The pediatric colonoscope, and particularly the newer Olympus PCF-100 colonoscope, is very useful in adult patients in whom it is not possible to traverse a fixed, angulated sigmoid colon or stricture using the standard adult colonoscope. This is predominantly a problem of female patients. Previous pelvic surgery may be an important causative factor in this regard.

Colon↗
PubMed1996

Photodocumentation of total colonoscopy: how successful are endoscopists? Do reviewers agree?

BACKGROUND: Documentation of total colonoscopy usually rests on a statement in the endoscopy report indicating that cecal landmarks were visualized. We sought to determine whether providing photographs of cecal landmarks provided an objective marker of complete colonoscopy. METHODS: We had 12 outside experienced endoscopists review 120 photographs of cecal landmarks that had been included with colonoscopy reports from our center that included 20 consecutive cases of reported total colonoscopy from each of 6 endoscopists. Reviewers graded whether they believed each set of photographs documented that at least the cecal inlet was reached as definite, probable, or uncertain. RESULTS: There was considerable disparity among reviewers as to whether individual photographs documented total colonoscopy. The frequency of combined, definite, and probable scores that they gave for the 120 photographs ranged from 97% down to 44% (median 82%). Different endoscopists also seemed to be variably successful in photodocumenting total colonoscopy. Four of the endoscopists received definite and probable scores for their 20 cases at least 80% of the time (86% for the highest ranked endoscopist). The lowest ranked endoscopist received such scores just 64% of the time. CONCLUSIONS: Documenting total colonoscopy with static images of cecal landmarks is only partially successful as an objective measure of the extent of total colonoscopy.

Cecum↗
PubMed1996

The palatability of five colonic lavage solutions.

BACKGROUND: Many patients dislike the taste and saltiness of polyethylene glycol-electrolyte colonic lavage solutions. Several commercially available lavage solutions have been introduced with reduced salt content or flavouring added in an attempt to improve palatability and to encourage patient compliance. AIM: To determine which of the commercially available lavage solutions are the most palatable. METHODS: A taste test of the five commercially available lavage solutions was performed by two groups of subjects: (a) adult patients scheduled to undergo colonoscopy (n = 50) and (b) adult family members of patients scheduled to undergo colonoscopy and hospital volunteers (n = 50). Subjects sampled all five products and were asked to grade the taste and saltiness, and to rank them in their overall order of preference. RESULTS: Similar findings were observed in the two groups of subjects. Colyte-Flavored, Cherry-NuLytely, NuLytely and GoLytely had similar median taste scores and a similar frequency of taste scores labelled as 'unacceptable' (8-11%); these four products ranked ahead of plain Colyte (which had a 25% frequency of taste scores labelled as 'unacceptable'). However, in the ranking phase of the study, about three-quarters of the subjects preferred a flavoured lavage solution to an unflavoured one. Colyte-Flavored and Cherry-NuLytely rated almost equal. Twenty-two per cent of subjects rated an unflavoured lavage solution (generally NuLytely or GoLytely) as their first choice. This included a subset of subjects who disliked the flavoured solutions and greatly preferred an unflavoured product. CONCLUSIONS: Four of the five commercially available products studied received similar taste scores. However, in the direct comparison phase of the study, a majority of subjects expressed a preference for a flavoured lavage solution. On the other hand, about one in five subjects expressed a dislike for the available flavoured solutions and preferred an unflavoured one.

Adolescent↗
PubMed1996

Ascites associated with antibiotic-associated pseudomembranous colitis.

We report the case of an elderly patient who had ascites due to pseudomembranous colitis and associated hypoalbuminemia. Computed tomography showed diffuse colonic wall thickening. An indium-111 scan to localize the site of infection showed abnormal localization of 111In throughout the colon. Despite treatment, the patient died. Autopsy disclosed no other cause for the ascites, except for possible sepsis. To study the cause of ascites in patients with pseudomembranous colitis, we reviewed our institutions' experience with ascites in association with Clostridium difficile colitis, identifying 16 cases over a 1-year period (which included our case). In most of the other cases, the ascites could be attributed primarily to another mechanism, including portal hypertension, congestive heart failure, and sepsis (intra-abdominal and systemic). We also reviewed the literature regarding the association of ascites with C difficile colitis.

Aged↗
PubMed1996

Colorectal cancer screening: present strategies and future prospects.

Considerable controversy remains as to what represents the most effective and cost-effective approach to screening for colorectal cancer. The American Cancer Society (ACS), whose guidelines are the most widely used in the United States, recommends annual fecal occult blood testing and flexible sigmoidoscopy every 3 to 5 years beginning at age 50 in asymptomatic, average-risk individuals. However, the high rates of false-positive and false-negative results associated with the fecal occult blood testing techniques currently available continue to represent a concern. There is sufficient information to encourage patients and physicians to comply with ACS recommendations for colorectal cancer screening. However, reducing the mortality and morbidity of colorectal cancer will require advances in screening methodology as well as new methods of educating both the public and physicians about the importance of screening. Future screening strategies may include improved fecal occult blood testing, use of colonoscopy (as either a one-time or a periodic examination), and molecular genetic testing performed on feces or blood. Advances in understanding of genetic alterations in colorectal cancer will undoubtedly improve our ability to target aggressive screening strategies and implement preventive measures.

Colonoscopy↗
PubMed1996

Efficacy and safety of combined meperidine and midazolam for EGD sedation compared with midazolam alone.

BACKGROUND/AIMS: Safety concerns have been raised about the use of the combination of an opioid and benzodiazepine for esophagogastroduodenoscopy (EGD) sedation, a common practice of American gastroenterologists. If we could show that patients in American practice settings satisfactorily tolerate EGD with midazolam alone, as is commonly done in Europe, it would provide impetus for American gastroenterologists to change practice habits. METHODS: We performed a randomized, double-blind trial to determine whether meperidine, used in addition to midazolam, improved patient tolerance to EGD compared with the use of midazolam alone in our academic practice setting. Safety parameters were also examined. One hundred twenty adult patients undergoing diagnostic EGD were randomized to receive either 50 mg of meperidine (group I) or 1 mg of midazolam (group II). Patients were then given additional midazolam in incremental doses at the discretion of the attending gastroenterologist to induce a state of conscious sedation. RESULTS: Including the study drug, patients in group I received an average of 1.8 mg less of midazolam compared with group II (mean total midazolam dose, 3.8 mg vs 5.6 mg; p = 0.037). Patients in group I showed improved tolerance for EGD compared with those in group II in terms of a physician rating of "poor" for the overall adequacy of sedation (7 vs 20%, p = 0.033), the need for supplemental narcotics or droperidol during the procedure (7 vs 20%, p = 0.033), the need for additional medication during intubation of the esophagus (12 vs 25%, p = 0.06), the need for a faculty member to accomplish esophageal intubation (7 vs 20%, p = 0.051), the presence of retching, which interfered with the procedure (21 vs 39%, p = 0.046), and premature termination of the exam (0 vs 7%, p = 0.055). No difference was seen in the degree of amnesia, in the willingness of patients to undergo another EGD in the future, or in cardiorespiratory parameters. CONCLUSIONS: In our academic practice setting, 50 mg of meperidine given i.v. at the start of the procedure improved the ability of our patients to tolerate EGD from the endoscopists' standpoint. We found no difference in cardiorespiratory parameters between the groups.

Adolescent↗
PubMed1996

Severe dysphagia, dysmotility, and unusual saccular dilation (diverticulum) of the esophagus following excision of an asymptomatic congenital cyst.

Iatrogenic dysmotility syndromes, particularly achalasia-like conditions, occasionally complicate esophageal and paraesophageal surgery. We describe a patient who developed a very unusual (and as far as we know unreported) syndrome characterized by severe dysphagia, esophageal dysmotility (segmental simultaneous contractions of the distal esophagus), and very large saccular outpouching (diverticulum) involving the right wall of the distal half of the esophagus as a consequence of excision of an asymptomatic congenital cyst. The cyst had been discovered as an incidental finding on a preemployment chest x-ray. Our patient's dysphagia did not improve with nonsurgical treatments that are usually successful for idiopathic and iatrogenic achalasia.

Acute Disease↗
PubMed1996

Acute hepatitis associated with the use of a Chinese herbal product, ma-huang.

Herbal medicines are widely perceived by the public as being healthful and innocuous. A number of herbal medicines have now been linked with hepatotoxicity. We report a case of acute hepatitis associated with the use of ma-huang, a herbal product derived from plants of the Ephedra species, which is advertised as being useful for causing weight loss and enhancing energy levels. Given the lack of reports in the literature of hepatotoxicity with ma-huang and ephedrine, we speculate that the ma-huang product our patient took contained some other ingredient or contaminant or was misidentified. Our report and others in the literature, which we review, indicate that the clinician should consider herbal medicines as a possible cause of unexplained liver injury.

Acute Disease↗
PubMed1996

Esophageal dilation with polyvinyl (American) dilators over a marked guidewire: practice and safety at one center over a 5-yr period.

OBJECTIVE: Improvements in dilator technology over the past decade have revolutionized esophageal dilation. There remains, however, a number of controversies relating to several technical aspects of wire-guided dilation, including whether or not fluoroscopy is necessary. We describe our experience with wire-guided esophageal bougienage. METHODS: We retrospectively reviewed our experience with esophageal dilation using polyvinyl (American) dilators and marked guidewires over the period 1990-1994 to assess the practice habits of our endoscopists and the safety of the technique. We did 606 wire-guided dilations on 354 adult patients. Dilations were done by six different endoscopists. RESULTS: Fluoroscopy was used in only 32/606 dilations (5.3%) and then only to pass a guidewire when the scope could not be passed through the stricture. Fluoroscopy was not used to monitor dilator passage. Peptic strictures were dilated to their maximal target size (determined by the individual endoscopist) in one session in 195 of 253 instances (77.1%). Practice differences were seen between the individual endoscopists relating to how rapidly dilation was accomplished, the number of dilators passed per session, and the maximal dilator size passed. No perforations or other serious complications occurred in our series. CONCLUSIONS: Wire-guided esophageal bougienage is a very safe procedure when careful attention to technique is observed. No perforations were seen in our series of over 600 dilations. Fluoroscopy is needed only in those cases in which a scope cannot be passed through a stricture to assist with guidewire passage. In a majority of cases, peptic strictures can be dilated to a 45-to 51-Fr size in a single session.

Dilatation↗
PubMed1996

Are patients who undergo open-access endoscopy more anxious about their procedures than patients referred from the GI clinic?

OBJECTIVES: Our academic hospital center operates an open access endoscopy service that allows referring physicians to directly schedule patients for outpatient esophagogastroduodenoscopy and colonoscopy without having them first seen in the GI clinic. Although patients from the GI clinic have an opportunity to meet the endoscopist and discuss their procedures directly beforehand, patients who are scheduled to undergo endoscopy through our open access service receive only a brief telephone call from a GI fellow or nurse that is made to screen for contraindications to the procedure and to give instructions. Our objective was to find out whether patients who used our open access service were more anxious about their procedures than those referred from the GI clinic. METHODS: On arrival to our endoscopy center, consecutive patients from the open access service (n = 142) and the GI clinic (n = 85) completed a questionnaire that included three measures of anxiety. After completion of the endoscopic procedure, the attending endoscopist rated patient cooperation. Patients also completed a phone questionnaire on the day after their procedures assessing their experience with endoscopy. RESULTS: We found no difference between patients from the open access service and those from the GI clinic in any of the measures of preprocedure anxiety, in scores measuring cooperation during procedures, or in patient ratings of their experience with endoscopy as assessed on the day after procedures. CONCLUSIONS: Patients who used our open access service were no more anxious about their procedures or less cooperative during them than patients first seen in the GI clinic. In both groups, procedure-related anxiety was decreased in patients who had previously undergone endoscopy.

Adolescent↗
PubMed1995

Mediastinal histoplasmosis presenting with esophageal involvement and dysphagia: case study.

Esophageal involvement with histoplasmosis is uncommon, but has been recognized in two clinical settings. Most commonly, the esophagus becomes involved as a result of contiguous mediastinal lymphadenopathy. Such patients usually present with dysphagia secondary to midesophageal compression or stricture. The esophagus can also be involved in cases of disseminated histoplasmosis. Esophageal ulcers or nodular lesions are the usual clinical manifestations in this setting. We report a case of mediastinal histoplasmosis with esophageal narrowing and mucosal ulceration that presented with dysphagia. The diagnosis was established at thoracotomy by the histologic finding of necrotizing granulomas and a positive fungal stain. The case was successfully treated with amphotericin B. The literature on esophageal and gastrointestinal histoplasmosis is reviewed.

Adult↗
PubMed1995

Prospective, randomized trial comparing a new sodium phosphate-bisacodyl regimen with conventional PEG-ES lavage for outpatient colonoscopy preparation.

BACKGROUND: Several recent trials have shown that colonoscopy preparation with sodium phosphate solution is as effective and at least as well tolerated as conventional PEG-ES lavage. These trials utilized two 1.5-fluid oz doses, one given on the evening before colonoscopy and the other early the next morning. METHODS: We devised a new sodium phosphate regimen in which the entire dose was given on the evening before examination (1.5 fl oz at 4 PM, 1.5-fl oz at 7 PM and 10 mg of bisacodyl at 10 PM) and performed a prospective, randomized trial that compared it with conventional PEG-ES lavage in terms of quality of colon cleansing, patient tolerance, and safety in an outpatient colonoscopy population with normal renal function. Seventy-two patients received sodium phosphate-bisacodyl and 75 PEG-ES lavage. RESULTS: The overall quality of colon cleansing and frequency of unsatisfactory preparations were similar with both methods. Patients found preparation with sodium phosphate-bisacodyl to be easier than PEG-ES lavage (p = 0.005). No clinically important adverse effects were seen with either method of preparation. The average cost of sodium phosphate-bisacodyl was $4.32 per patient compared with $18.15 for PEG-ES lavage preparation. CONCLUSION: Preparation with sodium phosphate-bisacodyl, given on the evening before colonoscopy, is a well-tolerated, efficacious, and cost-effective alternative to conventional PEG-ES lavage.

Adolescent↗
PubMed1995

Technical proficiency of trainees performing colonoscopy: a learning curve.

BACKGROUND AND PURPOSE: We sought to provide an objective measure of the technical progress of trainees learning colonoscopy. GI fellows in our training program perform colonoscopy under supervision throughout their 2 years of fellowship. METHOD: The frequency of fellows reaching the cecum in less than 30 minutes was determined by one endoscopy instructor during the last 7 months of their first year of training and during the last 7 months of their second year. RESULTS: The mean success rate of reaching the cecum for seven first-year fellows was 54% (individual range, 25% to 86%). This compared with 86% for six second-year fellows (individual range, 73% to 93%) and with 97% for the endoscopy instructor when he did procedures without a fellow. First-year fellows during the 7-month "testing" periods believed they had reached the cecum in 5.7% of cases in which they had not. This was not a problem with second-year fellows. Counting colonoscopies done with all instructors in our program, fellows in this series each did an average of 149 colonoscopies during their first-year of training and 328 by the end of their second. CONCLUSIONS: Increasing proficiency in reaching the cecum occurs with experience over time, and continues even after completion of formal training. Individual trainees also seem to learn colonoscopy at different rates. Depending on how one defines competency, it is possible that the minimum threshold number for technical competency in colonoscopy of 100 procedures, as suggested by the ASGE, may be low.

Clinical Competence↗
PubMed1995

The effect of droperidol on objective markers of patient cooperation and vital signs during esophagogastroduodenoscopy: a randomized, double-blind, placebo-controlled, prospective investigation.

We investigated the effect of droperidol on objective markers of cooperation and vital signs in 140 patients undergoing elective diagnostic esophagogastroduodenoscopy. Procedure duration and the total doses of midazolam and meperidine required during the procedure were evaluated as objective markers of patient cooperation. The droperidol group comprised 66 patients and the placebo group 74 patients. Patient and procedure characteristics were similar for both groups. Droperidol produced a 10% reduction in procedure duration. Linear multiple regression modeling revealed droperidol to be a significant predictor of procedure duration (p = .036). Droperidol significantly reduced midazolam and meperidine requirements (p < .01). Nonetheless, four patients in the droperidol group received naloxone to reverse prolonged, excessive drowsiness. Droperidol produced a significant reduction in procedure-associated increase in pulse rate but did not exacerbate procedure-associated reduction in mean arterial pressure. Droperidol favorably influences markers of patient cooperation during elective, diagnostic esophagogastroduodenoscopy. However, the clinical significance of these changes is unclear.

Adjuvants, Anesthesia↗
PubMed1995

Association of systemic lupus erythematosus and gluten enteropathy.

Systemic lupus erythematosus presents various clinical manifestations. The coexistence of systemic lupus erythematosus and celiac sprue has been rarely reported. We present a patient who had systemic lupus erythematosus with malabsorption demonstrating characteristic clinical and pathologic findings of celiac sprue (gluten enteropathy).

Celiac Disease↗
PubMed1995

Severe gastroesophageal reflux disease. Medical and surgical options for long-term care.

Severe gastroesophageal reflux disease is usually a chronic problem with periods of relapse, but effective medical and surgical therapies are available. Two recently introduced agents, omeprazole (Prilosec) and cisapride (Propulsid), represent advances in medical therapy; the safety of long-term, continuous omeprazole therapy is under investigation. Used by surgeons with sufficient experience, the new laparoscopic approach offers potential advantages over conventional anti-reflux surgery in suitable candidates. The decision of whether to recommend long-term medical therapy or surgery must be individualized. Medical therapy may be the best choice in elderly patients and poor surgical candidates, in patients whose symptoms are well controlled with omeprazole and who accept its benefit-risk profile, and when a highly experienced anti-reflux surgeon is not available. Surgery may be appropriate (assuming a skilled surgeon is available) in patients who are young, have trouble taking medication, need multiple agents to control symptoms, and need continuous omeprazole therapy but are unwilling to accept the theoretical risk of gastric carcinoid tumors that accompanies it.

Antacids↗