Biomedical subjects
Publications and source records attributed to D E Fleischer.
Endoscopy has revolutionized all aspects of digestive diseases and has increased the popularity of gastroenterology and minimally invasive surgery. These changes as well as improved technology and innovative applications of standard procedures call for more sophisticated endoscopic training. This article discusses what that training and curriculum should be and how it can be conducted.
Upper gastrointestinal hemorrhage, although accounting for more than 300,000 annual hospital admissions in the United States, continued to have about a 10% mortality rate over the past 50 years. Whether this is secondary to the increasing age of patients admitted with UGI hemorrhage, and their comorbid diseases, is unknown. The major approach to these patients includes volume and cardiovascular resuscitation, as well as surgical and gastroenterology consultation. Both clinical signs and endoscopic features in patients aid in predicting those at high risk of either rebleeding or dying, allowing for more aggressive steps, including endoscopic therapy of the bleeding site and surgery. Improved intensive care measures and endoscopic therapies for these patients may account for the signs of a recent decline in this mortality rate during the past 10 years.
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The onset of UC and CD may occur later in life. Although making the diagnosis of IBD in the elderly can be challenging, the clinical course, natural history, and response to treatment are similar for older and younger patients. In fact, both UC and CD tend to be less extensive in older patients, a feature that may contribute to the overall favorable prognosis for elderly patients with IBD. Overall mortality rates for both UC and CD appear to be similar to that of the general population except for those few patients that present with severe initial disease. Typical features of IBD in the elderly are summarized in Table 3. The differential diagnosis of IBD in the elderly includes infectious causes of enterocolitis, ischemic colitis, and diverticular disease as well as several other mimics of IBD. Awareness of the possibility of late-onset disease and the unique manifestations of disease in the elderly contributes to accurate diagnosis and timely treatment.
Neodymium:YAG laser therapy has been shown to be a safe and effective palliative treatment for esophageal cancer. Exophytic tumors in a straight segment of the mid- and distal esophagus are most amenable to therapy. Perforation or fistula, the most serious complications, occur in less than 5% of patients.
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The approach to nonvariceal UGI bleeding has been reviewed. Therapeutic endoscopy has been shown to be superior to medical therapy in patients with an actively bleeding ulcer and those at high risk of rebleeding. Of endoscopic therapies available to the GI endoscopist, multipolar electrocoagulation, heater probe, and injection therapy are comparable in efficacy and safety.
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Lasers have been used endoscopically in the management of gastrointestinal (GI) diseases for 15 years. Although the initial use was for therapy of GI bleeding, other more portable less expensive modalities have supplanted the laser in this area. Currently, its primary application is for therapy of GI neoplasms. If lasers are to be used with increased frequency, it will require that its unique property--selective absorption--be more of a focus than simply using it as a thermal device. Pigmented vascular lesions such as angioma or watermelon stomach are ideally suited for laser therapy using a wavelength preferentially absorbed by hemoglobin. The future use of lasers for gastrointestinal diseases--both diagnostically and therapeutically--will depend on taking advantage of this unique characteristic of laser light.
Laser therapy and BICAP tumor probe therapy offer effective and safe means of palliating obstructive esophageal cancer. Future developments may allow more precise application of these techniques, based on more sensitive means of identifying abnormal tumor tissue. The development of endoscopic ultrasonography and the use of tissue sensitizing agents (such as hematoporphyrin derivatives) may allow more accurate means of differentiating normal from abnormal tissue. This may lead to more precise and extensive tumor destruction, less injury to normal tissue, and less potential for complication. As the use of both of these modalities becomes more widespread, their role in the treatment of esophageal cancer will continue to grow.
A combined radiologic and endoscopic approach to the removal of an occluded double-mushroom biliary endoprosthesis was successfully performed in a patient with terminal pancreatic carcinoma. The present technique is beneficial when there is limited percutaneous and endoscopic access to the biliary system.
It has been estimated that gastrointestinal (GI) bleeding occurs in more than 100,000 patients with peptic ulcer disease each year. In 75-80% of the cases, bleeding will be self-limited. A major predictor of persistent or recurrent bleeding is the magnitude of blood loss before the initial evaluation. Endoscopy has an important role in the evaluation of the patient with suspected or presumed upper GI bleeding. Active bleeding at the time of the endoscopy correlates with the more likely probability of persistent bleeding, which carries a higher morbidity and mortality. In addition, there has been continued interest in the finding of a visible vessel. Although there is some controversy as to what a visible vessel actually is and how closely observations will agree about its recognition, there is general agreement that it is an important endoscopic finding and that it carries a high likelihood of rebleeding. In addition to the finding of a visible vessel, many endoscopists feel that ulcers found in the posterior-inferior wall of the duodenal bulb and high on the lesser curve of the stomach should be considered in a separate category. Owing to their proximity to large vessels, some feel that endoscopic management carries a greater risk because of the possibility of inducing bleeding. A wide variety of endoscopic approaches are available for the therapy of upper GI bleeding. It is convenient to divide these therapies into four categories: (a) topical, (b) injection, (c) mechanical, and (d) thermal. Endoscopic therapy for bleeding ulcers has generally been performed with a high degree of safety.(ABSTRACT TRUNCATED AT 250 WORDS)
A 77-yr-old man with chest discomfort and progressive dysphagia was found to have an intraluminal esophageal lesion of remarkable size. A giant fibrovascular polyp (11 x 7 x 3.5 cm) was successfully removed surgically by a transcervical approach. This unusual benign esophageal lesion is discussed in terms of classification and clinical presentation from a historical perspective. Particular attention is focused on the current approach to diagnosis and management. Endoscopic ultrasonography was employed as part of the evaluation.
Colorectal cancer is the second most common cause of cancer in the United States. The overall mortality rate approaches 60%. However, the detection of early lesions results in a mortality rate of 20% or less. Therefore, if improvement in survival is to occur, increased efforts need to be focused not only on primary prevention but also on early detection of malignant lesions and the eradication of potentially malignant lesions. There is no universal consensus as to how this can be accomplished. The purpose of this article is to serve as a guideline, providing a practical basis for improving early detection and management of colorectal cancer and its precursors.
This case report describes a patient with esophageal carcinoma and tumor-associated gastroparesis. The radionuclide gastric emptying study diagnosed very delayed liquid and solid gastric emptying. Metoclopramide was administered intravenously during the study and was able to predict a good response to oral therapy.
New technology has combined the endoscope with ultrasound in an effort to enhance the visualization of the gastrointestinal tract. With a modified standard endoscope that has an ultrasound transducer built into the tip, high frequency ultrasonic beams can be targeted in close proximity to existing lesions. This results in better quality resolution which enhances the evaluation of the targeted lesion. In addition, esophageal wall thickness can be evaluated and assessed as to its role in esophageal function.
Because the rates of morbidity and mortality from gastrointestinal (GI) bleeding in the elderly are substantially higher than those seen in younger patients, practitioners caring for the elderly should be familiar with aspects of GI bleeding that are unique to this population. A discussion of the differential diagnosis of upper GI tract bleeding is followed by a review of approaches for diagnosis and treatment.
Lower GI bleeding in the elderly can be attributed to diverticula or vascular ectasias in most cases. Usually, a diagnosis is established by colonoscopy, but often this test must be supplemented by radiographic and additional endoscopic techniques, especially in the evaluation of obscure GI bleeding. Responsible lesions are frequently remediable by non-operative therapy. However, if surgical intervention is called for, it should not be delayed solely because of the patient's advanced age.