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Biomedical subjects

J S Goff

Publications and source records attributed to J S Goff.

At least 19 recordsLinked to original sources
PubMed1995

Effect of propofol on human sphincter of Oddi.

The effect of propofol was studied in 11 patients who had common bile duct sphincter of Oddi manometry for suspected dysfunction. Patients were initially sedated with midazolam and then further or resedated with propofol for the second set of pressure measurements. Recordings were made about 10 min after giving each drug. No patient had elevated basal pressure initially. Average basal pressure was unchanged (16.7 +/- 16.4 mm Hg), phasic contraction frequency was unchanged (3.4 +/- 3.8/min), and phasic contraction amplitude fell but did not achieve statistical significance (91.8 +/- 77.3 mm Hg, P = 0.1). There was no difference in lowest blood pressure, pulse, or oxygen saturation recorded during midazolam or propofol sedation. Subjectively, the patients were more sedated during propofol administration. It is concluded that propofol is a safe and effective agent for conscious sedation. It does not alter the sphincter of Oddi pressure profile in patients with normal basal sphincter pressures and thus could be used as an alternative and perhaps better form of sedation for ERCP with sphincter of Oddi manometry.

Adolescent↗
PubMed1995

Common bile duct sphincter of Oddi stenting in patients with suspected sphincter dysfunction.

OBJECTIVES: Some patients seem to have symptoms or other findings that imply that they have sphincter of Oddi dysfunction, but when the sphincter pressure is measured, the basal resting pressure is not greater than 40 mm Hg. Because empiric sphincterotomy can alleviate some of these patients'symptoms, it is suspected that they have intermittent spasm or dysfunction. Prolonged stenting of the sphincter would prevent symptoms in patients with this intermittent disorder. Thus, one could determine which patients would benefit from a sphincterotomy without subjecting all the patients to the risk of sphincterotomy. METHODS: Twenty-one patients with suspected sphincter of Oddi dysfunction were studied. All had basal sphincter of Oddi pressures < 40 mm Hg. The gallbladder was in situ in three. The others had persistent abdominal pain after cholecystectomy. Benefit was defined as no symptoms for 2 months after stent placement, followed by continued lack of symptoms once a sphincterotomy was performed. RESULTS: Nine patients benefited and 12 did not. One relapsed, but benefited from a repeat sphincterotomy. Eight patients (38%) met criteria for pancreatitis after stent placement. Two had severe pancreatitis with pseudocyst development. There were no sphincterotomy-related complications. CONCLUSIONS: The results suggest that patients without basal resting sphincter of Oddi pressure criteria may have intermittent spasm or dysfunction which can be deduced by achieving benefit after stenting, but the risk of pancreatitis from this technique as described is too high to recommend stenting as a routine method for detecting patients with intermittent sphincter dysfunction/spasm. Alternate methods need to be developed to identify these patients.

Abdominal Pain↗
PubMed1992

Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices.

BACKGROUND: Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques. METHODS: In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival. RESULTS: Active bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12 of 14 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication of varices required a lower mean (+/- SD) number of treatments with ligation (4 +/- 2 vs. 5 +/- 2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041), as was the rate of complications (22 percent vs. 2 percent, P less than 0.001). The complications of sclerotherapy were predominantly esophageal strictures, pneumonias, and other infections. CONCLUSIONS: Patients with cirrhosis who have bleeding esophageal varices have fewer treatment-related complications and better survival rates when they are treated by esophageal ligation than when they are treated by sclerotherapy.

Esophageal and Gastric Varices↗
PubMed1992

Precholecystectomy endoscopic cholangiography and stone removal is not superior to cholecystectomy, cholangiography, and common duct exploration.

Thirty-four patients with suspected common bile duct stones were randomized to undergo endoscopic cholangiography and stone removal prior to open cholecystectomy or to have open cholecystectomy, operative cholangiography, and common bile duct exploration. Sixteen underwent the first protocol, and 18 the second. Analysis of the ability to clear stones from the common bile duct, morbidity, mortality, hospital stay, length of operation, and hospital cost showed no difference in outcome between patients treated by either method. These data suggest there is neither an advantage nor a disadvantage to treating patients with suspected duct stones by precholecystectomy endoscopic cholangiography and stone removal.

Adult↗
PubMed1992

Three years experience with endoscopic variceal ligation for treatment of bleeding varices.

Endoscopic variceal ligation (EVL) was developed as an alternative to endoscopic variceal sclerosis (ES) because of the high complication rate seen with ES. The new technique involves placement of small elastic bands around the variceal channels in the distal esophagus. The first 146 consecutive patients treated with EVL during the period from August, 1986 to July, 1989 are reported. Portal hypertension was caused by alcoholic liver disease in 93 of these patients. The average age of the patients was 53 years and 66% were males. All of the patients had recently bled from esophageal varices. At the time of treatment, 23% of the patients were actively bleeding. They were all treated acutely with EVL and had repeated treatments with the long-term goal of variceal eradication. The overall survival was 73%. Varices were eradicated or reduced to grade one in 78% of the 125 patients who were followed for more than 30 days. Variceal eradication required a mean of 5.5 sessions. Recurrent bleeding occurred in 44% of the total patient population. There were no major complications from EVL. It is concluded from this non-randomized experience that EVL is an effective treatment for bleeding esophageal varices and that it appears to be as effective as sclerotherapy with fewer complications.

Esophageal and Gastric Varices↗
PubMed1991

The effect of intravenous diazepam on esophageal motility in normal subjects.

Controversy exists over whether diazepam can be used for sedation during esophageal manometry studies without affecting the results. To evaluate the effect of diazepam, 20 healthy asymptomatic volunteers were studied using a standard manometry protocol employing an Arndorfer capillary infusion system. Following a baseline manometry, each subject received 0.1 mg/kg diazepam intravenously over 1 min and underwent repeat manometry 5 min after completion of the injection. All manometry recordings were coded and read blindly. The amplitude of the lower esophageal sphincter was significantly reduced by diazepam from 26.2 +/- 10.9 and 30.0 +/- 10.9 mm Hg to 18.8 +/- 7.6 and 24.5 +/- 9.7 mm Hg by rapid and station pull-through methods, respectively (P less than 0.01 both methods). Esophageal contraction wave duration was significantly increased following diazepam at 3, 8, and 13 cm above the lower esophageal sphincter (P less than 0.01 all levels). There was a trend toward increased contraction wave amplitude following diazepam administration in the lower three fourths of the esophagus. On the basis of these results, we conclude that diazepam sedation may produce misleading results when used during esophageal manometric testing. It is recommended that diazepam not be used in manometric studies of normal subjects or patients with reflux esophagitis and that manometric findings in patients with hypertensive or spastic disorders be interpreted with caution if diazepam is given as a premedication.

Adult↗
PubMed1991

Collagenous colitis with involvement of terminal ileum.

We present a case of collagenous colitis with evidence of terminal ileal involvement. The patient suffered from chronic watery diarrhea of three months' duration, and colonoscopy revealed a normal endoscopic appearance. Histologic examination of biopsies revealed a broad subepithelial band of collagen, with similar histologic findings in the terminal ileum. Additionally, the patient exhibited abnormalities of d-xylose and vitamin B12 absorption, although there were no clinical signs of malabsorption. Biopsy of the proximal small intestine was normal. The significance of these findings for the definition of the clinicopathologic entity of collagenous colitis and its pathogenesis are discussed.

Colitis↗
PubMed1991

Assessment of the risk of bleeding from esophageal varices by continuous monitoring of portal pressure.

Portal pressure was monitored by means of an indwelling hepatic vein balloon catheter in patients with alcoholic cirrhosis and bleeding varices to determine the safety and feasibility of the technique and its value in predicting recurrence of bleeding. Forty patients were enrolled. Central venous access could not be achieved in 4 patients (10%). Hepatic vein catheterization was accomplished in the remaining 36 patients. Fourteen patients were either later found to have nonalcoholic liver disease or had already received treatment that excluded them from the protocol. The remaining 22 patients, who were treated with blood and fluid replacement, were monitored for up to 72 hours. Portal pressure was greater than 11 mm Hg in all patients (normal, less than 5 mm Hg) and did not change significantly over the 3 days of study. Portal pressure was significantly higher in the 9 patients who continued to bleed or rebled compared with the 13 patients who remained stable. The lowest pressure associated with continued bleeding or rebleeding was 16 mm Hg. Continuous monitoring of portal pressure in patients with bleeding esophageal varices due to alcoholic cirrhosis is safe and feasible and permits rapid stratification of the risk of continued bleeding or early rebleeding.

Adult↗
PubMed1990

Endoscopic ligation of esophageal varices.

One hundred consecutive patients with bleeding esophageal varices were treated with a new endoscopic ligating device that effects strangulation of varices using small elastic "O" rings. Treatments were continued after initial hospitalization to achieve variceal eradication. Follow-up ranged from 6 to 26 (mean: 15) months. Bleeding was controlled until discharge from hospital or death in 18 of 21 patients who were actively bleeding at index endoscopy. Overall, 26 patients died during the study, 12 during the index hospitalization. Cause of death was organ failure in 21, exsanguination in 3, and cancer in 2. Forty-one of 88 initial survivors experienced 72 episodes of recurrent bleeding (1 to 4 per patient). All but five rebleeds occurred before eradication. Sixty of 88 patients (68%) who survived index hospitalization had their varices eradicated. A median of 5 (1 to 12) treatments was required. Nine patients eventually had other forms of treatment for recurrent bleeding. Only 3 non-bleeding complications resulted from 462 endoscopic treatment sessions. We conclude that endoscopic ligation controls active variceal bleeding and eradicates varices with efficacy similar to that of sclerotherapy and with minimal risk of complications.

Adult↗
PubMed1990

Direct catheterization of the mesenteric vein: combined surgical and radiologic approach to the treatment of variceal hemorrhage.

Minilaparotomy and direct catheterization of the mesenteric vein for variceal embolization was attempted in 15 patients in whom medical and endoscopic treatment of variceal hemorrhage had failed. Hemorrhage was controlled immediately after the procedure in 11 patients. The 30-day survival rate was 60% (n = 9). The cause of death in six patients was variceal bleeding (n = 2), liver failure (n = 3), and respiratory failure (n = 1). The 6-month survival rate was 33% (n = 5), and the 1-year survival rate was 27% (n = 4). Bleeding recurred in 67% of surviving patients; however, fatal variceal bleeding occurred in only 22% (n = 2). Direct mesenteric vein catheterization allows simplified entry into the portal vein for embolization of bleeding esophageal or gastric varices. Early experience suggests that the results are similar to those of percutaneous transhepatic embolization, without the complications and technical demands of a transhepatic approach.

Adult↗
PubMed1989

Endoscopic cholangiography and stone removal prior to cholecystectomy. A more cost-effective approach than operative duct exploration?

Would economic benefit result from performing endoscopic cholangiography and removal of common bile duct stones prior to cholecystectomy in patients who are suspected preoperatively of having choledocholithiasis? In this study, 173 patients had cholecystectomy and 30 (17%) had common bile duct exploration. Records of these patients were reviewed as were those of 31 patients who had only endoscopic cholangiography and endoscopic stone removal. Cost estimates were based on local charges. Cholecystectomy with common bile duct exploration was $6730 more per patient than cholecystectomy alone. Endoscopic cholangiography and endoscopic stone removal was 87% successful in removing duct stones. Had endoscopic cholangiography and endoscopic stone removal been performed preoperatively in patients undergoing cholecystectomy who had suspected choledocholithiasis, 21 of 30 common bile duct explorations could theoretically have been eliminated. This would have saved $85,526 or $2851 per patient undergoing common bile duct exploration. Our analysis suggests that patients who require cholecystectomy and have suspected choledocholithiasis may be treated more cost-effectively by performing endoscopic cholangiography and endoscopic stone removal immediately prior to cholecystectomy than by cholecystectomy and operative common bile duct exploration.

Adolescent↗
PubMed1989

Technique and early clinical results of endoscopic variceal ligation (EVL).

Endoscopic variceal ligation (EVL) is a new technique designed to be used instead of sclerotherapy. Small elastic "O" rings ligate varices resulting in their strangulation and eradication. During a 12-month period, EVL was employed in 53 consecutive patients, of whom 36 (68%) had alcoholic cirrhosis 17 were Child-Pugh class A, 22 class B, and 14 class C. Varices were graded from I to IV and repeat treatments were given at 1-2 week intervals until the varices were eliminated. At follow-up ranging from 6-18 months (mean 11.5), 217 EVL treatment sessions had been performed. Of the 13 patients (24%) who died during the study, 11 died during the index hospitalization. Active bleeding was controlled in 19 of 21 patients (90%). Of 40 survivors 13 patients (33%) had 1-2 (mean 1.4) recurrent variceal bleeds while 34 patients had repeat EVL treatment. Elimination of distal varices was achieved in 26 and 7 had reduction of varices from grade III-IV to grade I-II or less. Eradication required a mean of 4.4 EVL sessions in Child's A and B patients and 7.0 sessions in Child's C patients (P less than 0.025). No significant treatment-related complications were observed. EVL appears to control active bleeding, is associated with a low incidence of non-bleeding complications, and may be used as an alternative to sclerotherapy.

Child↗
PubMed1989

Endoscopic elastic band ligation for active variceal hemorrhage.

The purpose of this study was to assess the efficacy of EVL for treatment of active variceal hemorrhage. Twenty-three consecutive patients with actively bleeding esophageal varices had EVL with a flexible gastroscope. Treatment was measured by initial control of bleeding, incidence of early and late rebleeding, survival, complications, and size of varices at subsequent endoscopy. Repeat EVL was performed as needed for bleeding and at two week intervals until varices were grade I or eradicated. Follow up of survivors ranged from 90 to 400 days (mean 280). Bleeding varices were initially controlled in 22 (95.6%) patients. Nine (39.1%) died, five from hepatic failure with no recurrent bleeding, four from continued (1) or early recurrent (3) hemorrhage. All deaths occurred within 3 to 24 days (mean = 9.4) of initial treatment for active bleeding. Twelve of 14 surviving patients have achieved variceal eradication or reduction in size to grade I or less with a mean of 5.5 repeat EVL sessions (range, 0-10). One refused further treatment; one is lost to follow up. Excluding rebleeding, there were no treatment-related complications in 80 EVL sessions. Active variceal bleeding requiring endoscopic control is associated with substantial mortality, especially in higher risk patients. EVL is effective for initial and long term control of bleeding. EVL appears to be associated with a low incidence of non-bleeding complications.

Adolescent↗
PubMed1988

Infectious causes of esophagitis.

In recent years there has been an increasing awareness of infections in the esophagus and their potential to cause considerable morbidity and mortality in both normal subjects and immunocompromised patients. It is important to be cognizant of the pathogens involved, because their treatment is quite different from noninfectious esophagitis, and because inadequate treatment can lead to local complications in the esophagus or to dissemination of the infectious agent, especially in the immunocompromised host. Also, the esophagus is a site where opportunistic infections may present as one of the manifestations of the acquired immune deficiency syndrome (AIDS).

Bacterial Infections↗
PubMed1988

The human sphincter of Oddi. Physiology and pathophysiology.

The sphincter of Oddi (SO) is critically located at the junction of the common bile duct (CBD), main pancreatic duct, and the duodenum. It is a high-pressure zone with phasic contractions that regulate bile and pancreatic juice flow. The SO is probably regulated by several gastrointestinal hormones, and its basal pressure and phasic contractions can be elevated or decreased significantly by exogenous drugs. Its role in gallstone formation is probably negligible, but severing the SO allows one to extract CBD stones with an endoscope. Abnormal function of the SO can cause biliarylike pain. Of patients with persistent pain after cholecystectomy, 14% have abnormal SO manometric findings. Endoscopic or surgical sphincterotomy can cure these patients of their pain. The SO may play a significant role in the development of pancreatitis in certain patients, either because of the relationship of the CBD orifice to the pancreatic duct orifice created by the SO or because of the response of the SO to exogenous agents, such as alcohol.

Ampulla of Vater↗