Endoscopic management of acute colonic pseudo-obstruction.
Explore the source record for details and available documents.
Acute Disease↗
Biomedical subjects
M S Cappell
Publications and source records attributed to M S Cappell.
Diagnosis and treatment of nonsteroidal anti-inflammatory drug-associated upper gastrointestinal toxicity.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in the United States to treat pain and reduce inflammation from chronic inflammatory disorders such as rheumatoid arthritis and osteoarthritis. Approximately 40% of older Americans take NSAIDs. Chronic NSAID use carries a risk of peptic ulcer and other gastrointestinal disturbances. This article reviews the diagnosis of medication-induced ulcers based on clinical presentation, laboratory tests, and endoscopic findings to assist the clinician in early diagnosis and appropriate therapy. Risk factors for NSAID-induced ulcers include old age, poor medical status, prior ulcer, alcoholism, smoking, high NSAID dosage, prolonged NSAID use, and concomitant use of other drugs that are gastric irritants, such as alendronate, a bone resorption inhibitor prescribed for osteoporosis. Appropriate treatment options for patients with medication-induced ulcers include dosage reduction, medication substitution, medication withdrawal, antiulcer therapy, and discontinuation of other gastrotoxic drugs.
Anti-Inflammatory Agents, Non-Steroidal↗
Management of gastrointestinal bleeding induced by gastrointestinal endoscopy.
Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.
Endoscopy, Gastrointestinal↗
Fifty landmark discoveries in gastroenterology during the past 50 years. A brief history of modern gastroenterology at the millennium: Part I. Gastrointestinal procedures and upper gastrointestinal disorders.
During the last half century, many outstanding discoverers have revolutionized the clinical practice and science of gastroenterology. Whereas the scientific results are widely disseminated, the discoverers have received inadequate recognition, and the history of their discoveries is poorly known. At the millennium, a committee selected the 50 landmark discoveries in gastroenterology during the past 50 years. A brief history of each landmark discovery is presented. Part I presents the landmark discoveries in gastrointestinal (GI) procedures and in upper GI disorders. Part II of this presentation, which covers landmark discoveries in other areas of gastroenterology, will publish in Part II of the volume on High Risk Gastrointestinal Bleeding.
Gastroenterology↗
Acute gastrointestinal bleeding in the intensive care unit. The intensivist's perspective.
Gastrointestinal (GI) hemorrhage is a common and potentially lethal medical emergency that is a common cause for intensive care unit admission. The intensivist plays an important role as a member of the medical team managing the patient with GI bleeding who is at high risk because of severe bleeding, comorbidity, or the presence of endoscopic stigmata of recent hemorrhage. This article presents the intensivist's approach to GI hemorrhage in initial patient assessment, triage, resuscitation, specialist consultation, diagnostic evaluation, and medical therapy. This article focuses on types of GI bleeding of particular concern to the intensivist, including esophageal variceal bleeding, stress-related GI bleeding, and GI bleeding associated with myocardial infarcation.
Acute Disease↗
Gastrointestinal bleeding associated with myocardial infarction.
Gastrointestinal (GI) bleeding associated with myocardial infarcation (MI) often presents as a distinct syndrome that differs from either disease alone. MI is frequently overlooked in the setting of severe GI bleeding because the symptoms and signs of MI are frequently overshadowed by the severe bleeding. GI bleeding, particularly when massive, may precipitate MI from hypovolemia, hemodynamic compromise, and myocardial hypoperfusion. Esophagogastroduodenoscopy is safe in relatively clinically stable patients after MI and is indicated to evaluate significant upper GI bleeding.
Critical Care↗
Clinical scoring systems for determining the prognosis of gastrointestinal bleeding.
The prognosis of GI bleeding depends upon many factors. Patients should be evaluated carefully for risk factors. To avoid complications from GI bleeding, triage should be performed promptly after patient presentation. The history and physical examination should emphasize analysis of risk factors for severe GI bleeding and mortality. Factors that increase the morbidity and mortality include: age greater than 60 years; underlying comorbidity such as pulmonary diseases, liver diseases, renal diseases, encephalopathy, or cancer; physiologic stress from major surgery, trauma, or sepsis; coexisting disease in three organ systems; low hematocrit; melena or hematochezia; and prolonged prothrombin time. Hospitalized patients who require more than five units of packed erythrocytes transfusion or who develop hypotension or hypovolemic shock are more likely to need surgery. Patients with a high APACHE II score, the presence of esophageal varices, active bleeding, or other endoscopic stigmata of recent hemorrhage are more likely to rebleed and undergo surgery. The proliferation of multivariable prognostic scales, as described herein, provides ample evidence that the goal of developing a single comprehensive multivariable scale to accurately assess severity of disease and to determine prognosis of GI bleeding is still not achieved. Yet significant progress has occurred in this field, leading to the hope of developing a universally applicable multivariable scale.
APACHE↗
Radiology in the diagnosis and therapy of gastrointestinal bleeding.
Major breakthroughs in catheter and guidewire design as well as improvements in angiographic x-ray equipment currently allow interventional radiologists to diagnose massive life-threatening upper and lower GI hemorrhage and to stop the bleeding safely and effectively using superselective catheterization and microcoil embolization. For chronic or recurrent GI bleeding, when endoscopy is unrevealing or equivocal, barium studies, CT scanning, nuclear medicine studies, and angiography can help determine the cause of bleeding. A multidisciplinary approach, including the gastroenterologist, radiologist, and surgeon, is extremely helpful in managing GI bleeding, particularly in high-risk patients or patients presenting as diagnostic dilemmas.
Angiography↗
Fifty landmark discoveries in gastroenterology during the past 50 years. A brief history of modern gastroenterology at the millennium: Part II. Gastrointestinal motility, nutrition, and diseases of the lower gastrointestinal tract, liver, and pancreas.
During the last half century, many outstanding discoveries have revolutionized the clinical practice and science of gastroenterology. Although the scientific results are widely disseminated, the discoverers have received inadequate recognition and the history of their discoveries is largely unstudied and unknown. At the millennium, a committee selected 50 landmark discoveries in gastroenterology during the past 50 years. A brief history of each landmark discovery is presented. Part I was presented in the previous issue of Gastroenterology Clinics of North America. Part II presents landmark discoveries in gastrointerintal (GI) motility, clinical trials, nutrition, and diseases of the lower GI tract, liver, biliary tree, and pancreas.
Endoscopy, Digestive System↗
Safety and efficacy of esophagogastroduodenoscopy after myocardial infarction.
PURPOSE: To analyze the risks versus benefits of esophagogastroduodenoscopy performed soon after myocardial infarction. PATIENTS AND METHODS: We studied 200 patients who underwent endoscopy within 30 days after myocardial infarction with 200 controls matched for age, sex, and endoscopic indication who underwent endoscopy without a history of myocardial infarction within the prior 6 months. Odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: The indications for endoscopy included hematemesis in 88, melena in 43, fecal occult blood and anemia in 33, red blood per rectum in 13, abdominal pain in 13, and other indications in 10. Endoscopy was performed a mean (+/- SD) of 9.1 +/- 8.9 days after myocardial infarction, was diagnostic in 85% of all the patients, and was more frequently diagnostic when performed for hematemesis or melena than when performed for other indications (92% vs 71%, P <0.0003). Common diagnoses included duodenal ulcer, gastric ulcer, gastritis, and esophagitis. Fifteen post-myocardial infarction patients (7.5%) suffered endoscopic complications, including fatal ventricular tachycardia (n = 1), near respiratory arrest (n = 1), mild hypotension (n = 11), and moderate hypoxemia (n = 2), compared with three patients (1.5%) in the control group (OR = 5.3, CI = 1.5 to 19). Patients who had endoscopic complications after myocardial infarction had a significantly higher APACHE II score than those who did not (mean score of 17.3 +/- 5.8 vs 11.7 +/- 5.7, P <0.001). Endoscopic complications occurred in 21% (12 of 58) of post-myocardial infarction patients who were very ill (APACHE II score > or = 16) but in only 2% (3 of 142) of those whose condition was relatively stable (APACHE II score < or = 15, OR = 12; CI = 3.3 to 45). Hypotension before endoscopy and a high APACHE II score were independent risk factors for complications in post-myocardial infarction patients. CONCLUSIONS: Relatively stable patients with upper gastrointestinal bleeding and recent myocardial infarction can and should undergo esophagogastroduodenoscopy. Most endoscopic complications in these patients are cardiopulmonary, and they generally occur in very ill patients.
APACHE↗
Intestinal (mesenteric) vasculopathy. I. Acute superior mesenteric arteriopathy and venopathy.
Intestinal vasculopathy is not rare, comprising about 1 per 1000 hospital admissions. Primary mesenteric vasculopathy causes cardiovascular disease, whereas secondary mesenteric ischemia causes extrinsic vascular compression or vascular trauma. Acute superior mesenteric arteriopathy is caused by a mesenteric embolus, thrombus, or vasospasm (i.e., nonocclusive vasculopathy). Acute superior mesenteric venopathy is caused by a thrombus, which is often associated with a hypercoagulopathy. The clinical presentation of both diseases is often subtle and nonspecific at an early stage and becomes overt and specific only when advanced and severe, when ischemia progresses to necrosis. The mortality of acute superior mesenteric arteriopathy is still very high, whereas superior mesenteric venopathy is less rapidly progressive and has a lower, but still significant, mortality. Early diagnosis and aggressive therapy significantly reduces the mortality of these life-threatening diseases.
Humans↗
Intestinal (mesenteric) vasculopathy. II. Ischemic colitis and chronic mesenteric ischemia.
Ischemic colitis accounts for approximately half of all cases of mesenteric vasculopathy. The clinical presentation varies depending on underlying cause, extent of vascular obstruction, rapidity of ischemic insult, degree of collateral circulation, and presence of comorbidity. Ischemic colitis is usually diagnosed by colonoscopy. Only approximately 20% of patients require surgery because of signs or laboratory findings of peritonitis or because of clinical deterioration. Approximately 20% of patients develop chronic colitis from irreversible colonic ischemic injury, which manifests clinically as persistent diarrhea, rectal bleeding, or weight loss and endoscopically as a colonic stricture or mass. Chronic mesenteric ischemia is almost always caused by significant atherosclerotic stenosis involving at least two mesenteric arteries, usually the superior mesenteric artery and celiac axis. The classic symptomatic triad of postprandial pain, fear of eating, and involuntary weight loss occurs with advanced disease.
Colitis, Ischemic↗
The safety and efficacy of gastrointestinal endoscopy during pregnancy.
More than 12,000 pregnant patients in the United States per year have conditions normally evaluated by esophagogastroduodenoscopy (EGD). More than 6000 pregnant patient in the United States per year have conditions normally evaluated by sigmoidoscopy or colonoscopy. Endoscopy during pregnancy raises the unique issue of fetal safety, and endoscopic medications comprise a significant component of fetal risks from endoscopy. This article analyzes the safety of endoscopic medications during pregnancy, reviews the literature on the safety of gastrointestinal endoscopy during pregnancy, proposes guidelines for endoscopic indications during pregnancy, and describes modifications of gastrointestinal endoscopy during pregnancy to increase fetal and maternal safety.
Endoscopy, Gastrointestinal↗
Gastric and duodenal ulcers during pregnancy.
The frequency, symptoms, and complication rate of peptic ulcer disease appear to decrease during pregnancy significantly. Clinicians, however, often have to treat dyspepsia or pyrosis of undetermined cause because the frequency of pyrosis increases during pregnancy. Physicians are reluctant to perform esophagogastroduodenoscopy (EGD) during pregnancy for pyrosis to reliably differentiate gastroesophageal reflux from peptic ulcer disease. Dyspepsia or pyrosis during pregnancy first should be treated with dietary and lifestyle changes, together with antacids or sucralfate. When symptoms persist, H2 receptor-antagonists are recommended. If symptoms continue and are severe despite these interventions, the patient should be evaluated for possible EGD or proton pump inhibitor therapy during the second or third trimester.
Diagnosis, Differential↗
Colon cancer during pregnancy. The gastroenterologist's perspective.
Colon cancer during pregnancy is uncommon but not rare, with an estimated incidence of several hundred cases per year in the United States. This type of cancer tends to have a poor prognosis that is attributable to delays in diagnosis and advanced disease at diagnosis. The diagnosis frequently is delayed because symptoms of colon cancer, such as rectal bleeding, nausea and vomiting, and constipation, often are attributed to normal pregnancy or minor complications of pregnancy. Pregnancy affects the diagnostic evaluation and therapy of colon cancer because of fetal risks of diagnostic tests and therapy. Appropriate medical evaluation of significant lower gastrointestinal complaints during pregnancy can lead to an earlier and improved diagnosis.
Antineoplastic Agents↗
The pancreas in AIDS.
Although autopsy studies reveal significant pancreatic lesions in about 10% of AIDS patients, pancreatic lesions infrequently produce symptoms and are rarely recognized premortem. Patients with AIDS can develop pancreatic disease from causes not related to AIDS or AIDS-specific lesions. AIDS-specific causes include opportunistic infection, AIDS-associated neoplasia, and medications used to treat complications of AIDS. Pancreatic involvement is usually part of a widely disseminated tumor and rarely produces clinical symptoms.
AIDS-Related Opportunistic Infections↗
Cyclic neutropenia in Crohn's ileocolitis: efficacy of granulocyte colony-stimulating factor.
A 40-year-old patient with long-standing Crohn's ileocolitis in remission experienced cyclic neutropenia with a periodicity of 14 days. He was not receiving immunosuppressive or myelosuppressive therapy. The patient had Staphylococcus aureus bacteremia resulting from central catheter infection, which was refractory to antibiotic therapy during the period of severe neutropenia. When granulocyte colony-stimulating factor (G-CSF) was administered, the cyclic neutropenia rapidly disappeared, the neutrophil and leukocyte counts normalized, and the sepsis resolved. When G-CSF therapy was discontinued, the leukocyte and absolute neutrophil counts again declined. With reinstitution of therapy, the leukocyte and absolute neutrophil counts recovered and normalized. Crohn's ileocolitis remained in remission during G-CSF therapy. This report confirms and extends one previous report of cyclic neutropenia associated with Crohn's disease and demonstrates in one patient the efficacy and safety of G-CSF on the hematologic, bacteriologic, and clinical manifestations of cyclic neutropenia associated with Crohn's disease.
Adult↗
Atypical duodenal ulcer associated with the antiphospholipid antibody syndrome.
Explore the source record for details and available documents.
Antiphospholipid Syndrome↗