This article reviews the role of therapeutic endoscopy in the diagnosis and treatment of nonvariceal upper and lower gastrointestinal (GI) hemorrhage. The initial approach to patients with GI bleeding is reviewed. Endoscopic treatment of various stigmata of recent peptic ulcer hemorrhage is discussed in detail. Management of less common causes of nonvariceal bleeding, such as Dieulafoy's lesions, Mallory-Weiss tears, angiomas, and bleeding colonic diverticula is described. Recommendations for endoscopic techniques are based on the results of UCLA-CURE hemostasis studies.

Acute Disease↗

PubMed2000

1999 ASGE endoscopic ultrasound survey. ASGE Ad Hoc Endoscopic Ultrasound Committee.

BACKGROUND: Gastrointestinal endoscopic ultrasound (EUS) has become an important imaging modality for the diagnosis and staging of gastrointestinal disorders. This study assessed current EUS practice, training, coding, and reimbursement in the United States. METHODS: A direct mail survey was sent to members of the American Society for Gastrointestinal Endoscopy. RESULTS: There were 115 American respondents. The median age was 39 years, 57% were in academic practice, and 84% performed endoscopic retrograde cholangiopancreatography. The median number of EUS procedures performed was 200. In the preceding year, the median number of upper EUS was 60, lower EUS 10, and EUS/fine-needle aspiration 3. The most common indication was evaluation of esophageal or gastric lesions. Forty-six (40%) trained an average of 0.4 advanced fellows in EUS during the prior year. Of endosonographers involved in training, 53% thought formal training was necessary, for a median of 6 months and 100 procedures; 82% did not know whether they were reimbursed for EUS. There was great variation in the use of current procedural terminology (CPT) codes for lower EUS and upper EUS/fine-needle aspiration. CONCLUSIONS: EUS in the United States in 1999 is performed mostly by young, academic, interventional endoscopists. Diagnostic upper EUS is most commonly performed. Few new endosonographers are being trained. There is great variability in CPT coding of lower EUS and EUS/fine-needle aspiration procedures.

Adult↗

PubMed1999

Radiographic changes after colonoscopic decompression for acute pseudo-obstruction.

PURPOSE: Colonoscopy has been the principal tool for decompression in acute colonic pseudo-obstruction, known as Ogilvie's syndrome. The objectives of this study were to determine the immediate effect of colonoscopy on the cecal diameter (measured on supine radiographs) and to delineate possible correlations in the diameters of dilated segments of the colon. METHODS: The charts and radiographs of 24 patients who had colonoscopic decompression for acute colonic pseudo-obstruction between 1992 and 1997 at the San Diego Veterans Affairs Medical Center and the University of California, San Diego Hospitals were reviewed. We measured cecal, transverse, descending, and sigmoid colon diameters on serial radiographs up to the point of clinical resolution. RESULTS: Mean +/- standard deviation cecal diameter change (between initial and post-decompression films) was -2+/-3.4 cm at four hours and -2.2+/-3.3 cm one day after decompression. On the daily radiographs between colonoscopic decompression and clinical resolution, there was a close correlation between the diameter of the cecum and that of the transverse colon (P<0.05). There was no correlation between the cecal diameter and that of the descending or sigmoid colon. CONCLUSIONS: Colonoscopic decompression only causes a small decrease in cecal size in the patient with acute colonic pseudo-obstruction. Dilation patterns of the cecum and transverse colon are significantly correlated in acute colonic pseudo-obstruction. This correlation provides additional support to the contention that the same pathophysiology affects these two segments of the colon.

Acute Disease↗

PubMed1999

Role of EUS in the preoperative staging of pancreatic cancer: a large single-center experience.

BACKGROUND: Current methods for staging pancreatic cancer can be inaccurate, invasive, and expensive. Endoscopic ultrasound (EUS) is reported to be highly accurate for local staging of gastrointestinal tumors including pancreatic cancer. The aim of this study was to assess the utility of EUS and CT for staging pancreatic cancer by comparing staging accuracies in surgical patients and evaluating the potential impact of EUS staging and training. METHODS: This was a preoperative comparison of the diagnostic operating characteristics of these procedures in a referral-based academic medical center. Data were collected on 151 consecutive patients referred with confirmed pancreatic cancer between April 1990 and November 1996. All patients had preoperative CT and EUS performed for staging. In patients undergoing surgery, the surgical staging and/or findings were used to confirm EUS and CT staging. RESULTS: Eighty-one (60%) of 151 patients underwent surgery and made up the study subset. In these 81 patients, surgical exploration provided a final T staging in 93% (75 of 81), N staging in 88% (71 of 81) and data on vascular invasion in 93% (75 of 81). In the surgical patient group, with surgical correlation, EUS accuracy for T staging was as follows: T1 92%, T2 85%, T3 93%, and for N staging was: N0 72%, and N1 72%. CT accuracy for T staging was as follows: T1 65%, T2 67%, T3 38%, and for N staging was as follows: N0 52% and N1 100%. CT failed to detect a mass in 26% of patients with a confirmed tumor at surgery. Overall accuracy for T and N staging was 85% and 72% for EUS and 30% and 55% for CT, respectively. The ability to accurately predict vascular invasion was 93% for EUS and 62% for CT (p < 0.001). EUS was 93% accurate for predicting local resectability versus 60% for CT (p < 0.001). Last, the data were divided into two groups for the senior endosonographer's experience: procedures performed between 1990 and 1992 (98 cases) and 1993 and 1994 (53 cases). This analysis revealed that 7 of 9 instances of mis-staging (78%) occurred in the earlier group, during the learning phase for EUS. CONCLUSIONS: EUS is more accurate than CT for staging pancreatic malignancies, including predicting vascular invasion and local resectability. EUS staging was significantly better than CT for T1, T2, and T3 tumors. EUS staging accuracy improved after 100 cases, thus suggesting a correlation between the accuracy of EUS staging and the number of procedures performed.

Adult↗

PubMed1998

The relation of age, race, and gender to the subsite location of colorectal carcinoma.

Explore the source record for details and available documents.

Adult↗

PubMed1998

Preoperative staging of colorectal cancer by a 15 MHz ultrasound miniprobe.

Explore the source record for details and available documents.

Colonoscopy↗

PubMed1997

Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study.

BACKGROUND: Current methods for detecting mediastinal lymph node involvement with non-small-cell lung cancer can be inaccurate and are often invasive and expensive. OBJECTIVE: To assess the utility of endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography for the detection of metastases to the posterior mediastinal lymph nodes in non-small-cell lung cancer. DESIGN: Prospective preoperative evaluation of the diagnostic operating characteristics of these procedures. SETTING: Referral-based academic medical center. PATIENTS: 130 consecutive patients with non-small-cell lung cancer who were otherwise good surgical candidates. INTERVENTIONS: All patients had initial computed tomography of the chest; those with enlarged nodes were referred for endoscopic ultrasonography. Endoscopic ultrasonography-guided fine-needle aspiration biopsy was done on suspicious contralateral posterior mediastinal or subcarinal lymph nodes identified by ultrasonography. At surgery, lymph nodes were dissected and categorized by location and underwent histopathologic evaluation. RESULTS: 52 patients were ultimately enrolled in the study: Thirty-one had thoracotomy with mediastinal dissection, and 21 had tumors considered unresectable on the basis of preoperative evaluation. Ultrasonography without aspiration biopsy had an overall accuracy of 84% for predicting metastasis to lymph nodes; computed tomography had an accuracy of 49% (P < 0.025). Twenty-four patients had ultrasonography-guided aspiration biopsy; 14 of 24 were ineligible for surgery because cytology showed malignancy. Results of surgical pathology correlated with negative aspiration cytology results in 9 of 10 patients, the one node with false-negative results contained a 2-mm focus of cancer. The accuracy of ultrasonography-guided aspiration biopsy in diagnosing metastasis to lymph nodes was 96%; the results of this test prompted a change in management in 95% of the patients who had the procedure. CONCLUSIONS: Endoscopic ultrasonography alone or with fine-needle aspiration biopsy adds useful diagnostic information in determining metastasis to posterior mediastinal or subcarinal lymph nodes in patients with non-small-cell lung-cancer. These procedures are especially helpful in the preoperative evaluation of patients with suspicious contralateral mediastinal or "bulky" subcarinal nodes.

Biopsy, Needle↗

PubMed1997

Endoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonography.

BACKGROUND: Endoscopic ultrasound (EUS) accurately stages gastrointestinal malignancies but is less able to differentiate between neoplastic and inflammatory processes. EUS-guided fine-needle aspiration (EUS FNA) has been reported useful for obtaining a diagnosis in suspected gastrointestinal lesions. We report our entire experience with EUS FNA using both radial and linear array endosonography, including our diagnostic accuracy and complication rate. METHODS: Two hundred eight consecutive patients (119 men, 89 women) referred for EUS evaluation of suspected gastrointestinal or mediastinal masses underwent EUS-guided FNA. We performed EUS FNA using radial scanning or linear array endosonography and a 23 gauge, 4 cm needle or a 22 gauge, 12 cm needle. Data collected included lesion types, number of passes, complications, and diagnostic accuracy. RESULTS: Two hundred eight lesions were targeted, with a total of 705 FNA passes (mean 3.39 passes/patient). Overall diagnostic accuracy for our study population was 87% with a 89% sensitivity and 100% specificity. The diagnostic accuracy for each subgroup was 95% for mediastinal lymph node, 85% for intra-abdominal lymph node, 85% for pancreatic, 84% for submucosal, and 100% for perirectal masses. EUS FNA provided an adequate specimen in 90% of patients. The FNA results were similar for both types of endosonography. We observed immediate complications in 2% (4 of 208) of patients. All complications occurred with EUS FNA of pancreatic lesions and consisted of bleeding and pancreatitis in 2 patients each. For EUS FNA of pancreatic masses there was a 1.2% (2 of 121) risk of pancreatitis, 1% (1/121) risk of severe bleeding, and risk of death in less than 1%. CONCLUSIONS: EUS-guided FNA appears to be technically feasible, safe, and accurate for obtaining diagnostic tissue of suspicious gastrointestinal and mediastinal lesions and provides important preoperative information.

Adolescent↗

PubMed1997

Laparoscopy-assisted endoscopic removal of a stromal-cell tumor of the stomach.

Endoscopic resection of gastrointestinal tumors is being performed with increased frequency. Submucosal mass lesions pose a particular problem, because of the risk of malignancy and the risk of complications associated with endoscopic removal. Increased incidences of both perforation and bleeding have been reported. We report here on a case in which we used a combined approach that included gastrointestinal endoscopy, laparoscopy, and laparoscopic ultrasound to resect a gastric leiomyoma. We consider that this approach enhanced our diagnostic capabilities, provided intraoperative options for resection, and enhanced the safety of the procedure.

Adult↗

PubMed1997

Patient preferences for colorectal cancer screening.

BACKGROUND: New guidelines include several options for colorectal cancer screening. The goal of this study was to assess patient preferences for five approaches: no screening, fecal occult blood testing (FOBT), flexible sigmoidoscopy, barium enema, and colonoscopy. METHODS: Patients from offices of primary care providers listened to a scripted oral presentation while viewing a table describing five screening methods and their outcomes. Immediately following the presentation, the subjects completed a questionnaire assessing their most preferred screening option and their likelihood of undergoing each option. RESULTS: One hundred subjects aged 50 to 75 years participated. The average age was 64 years; 54 of the subjects were women, and 87 were white. Ninety-six percent of patients preferred to be screened by some method. When asked which test they would choose as their primary method of screening, 38% preferred colonoscopy, 31% preferred FOBT, 14% preferred barium enema, and 13% preferred flexible sigmoidoscopy. When asked how likely they would be to undergo each procedure on a 5-point scale, patients rated FOBT highest with an average score of 4.4, followed by colonoscopy (3.4), barium enema (3.4), flexible sigmoidoscopy (3.4), and no screening (1.5). Acceptance rates for these tests when recommended by their physician were 96% (FOBT), 82% (flexible sigmoidoscopy), 92% (barium enema), and 86% (colonoscopy). CONCLUSIONS: Patients indicated a strong preference for colorectal cancer screening, but they did not indicate a dominant preference for any single screening test. Physicians need to take into account individual patient preferences when making recommendations regarding colorectal cancer screening.

Aged↗

PubMed1996

Endoscopic ultrasound: improving GI diagnosis.

At present, the technique--which incorporates fiberoptic imaging--is best used for local staging of esophageal, pancreatic, and rectal cancer, characterization of submucosal gastrointestinal masses, and detection of common bile duct stones. Potential uses being investigated include transintestinal fine needle puncture to aspirate lymph nodes or tumors and assistance with various therapies.

Cholelithiasis↗

PubMed1996

Stent-induced pancreatic ductal and parenchymal changes: correlation of endoscopic ultrasound with ERCP.

BACKGROUND: Polyethylene pancreatic duct stents induce morphologic changes of the pancreatic duct in the majority of patients. This study was undertaken to determine if parenchymal abnormalities are present in patients undergoing short-term pancreatic duct stenting and to correlate these findings with the pancreatogram obtained at stent removal. METHODS: Twenty-five patients underwent pancreatic duct stenting and had an endoscopic ultrasound evaluation of the pancreas at stent removal. The pancreatograms were evaluated at stent removal for ductal irregularity, narrowing, and side branch changes. Endoscopic ultrasound was used to assess for differences in the echo characteristics of the pancreatic parenchyma around the stent compared with the rest of the gland. RESULTS: Of the 16 patients evaluated by ERCP at stent removal, 9 (56%) had 1 or more new ductographic changes. Endoscopic ultrasound identified parenchymal changes in the stented region in 17 of 25 patients (68%). Four patients who had parenchymal changes in the stented region on endoscopic ultrasound at stent removal had a follow-up study at a mean time of 16 months. Two patients had (new) changes suggestive of focal chronic pancreatitis in the stented region. CONCLUSION: Short-term pancreatic duct stenting induced both ductal and parenchymal changes in more than 50% of patients. Chronic pancreatitis may be a consequence of pancreatic duct stenting.

Cholangiopancreatography, Endoscopic Retrograde↗