Presidential address 1981: the A/S/G/E and its environment.
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Biomedical subjects
Publications and source records attributed to J D Waye.
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Forty-five patients with Crohn's disease in whom the upper gastrointestinal tract was normal by x-ray were examined by gastroduodenoscopy. Biopsies were analyzed histologically from the lower esophagus, body of the stomach, gastric antrum and duodenal bulb. Cell counts were made of 500 connective tissue cells of the duodenal mucosa. Histological examinations and cell counts of the duodenal mucosa were also performed on 50 healthy volunteers used as controls. Histological lesions were found in 19 Crohn's disease cases; 11 (24%) were considered pathologically diagnostic and all these were found in the antrum or duodenum. In 11 the mucosa was endoscopically normal. Granulomas were present in three cases (7%), all from normal appearing mucosa. Microscopic alterations of the antrum and duodenum, similar to findings in the normal appearing rectal mucosa, support the concept that Crohn's disease involves the entire alimentary canal and that lesions are seen grossly only where the disease is most advanced.
A prospective colonoscopic study of 642 consecutive patients demonstrated that 156 (66%) mass lesions including 131 polyps and 25 cancers were located within 60 cm of the anus and 82 (34%) mass lesions including 68 polyps and 14 cancers were located beyond 60 cm, the working length of the rigid sigmoidoscope. One hundred twenty-one (61%) polyps and 14 (36%) cancers were located above 25 cm but less than 60 cm from the anus, the working length of the flexible sigmoidoscope. Sixty-eight (34%) polyps and 14 (36%) cancers were located beyond the reach of the flexible sigmoidoscope. Although the flexible sigmoidoscope detects more lesions than the rigid sigmoidoscope, 50% of colon cancers located beyond detection by the rigid sigmoidoscope would not have been detected with the flexible sigmoidoscope. Of all mass lesions located beyond 25 cm, 38% would not have been detected with the use of the flexible sigmoidoscope. It appears that total colonoscopy rather than flexible sigmoidoscopy must play an increasingly prominent role in the evaluation of patients with suspected colonic mass lesions.
The small caliber peroral endoscope (GIF-P2) was efficient and safe in the detection of lesions in a series of 69 patients with acute upper gastrointestinal hemorrhage. The authors describe a technique of examination that they have found appropriate to this problem.
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A patient with traumatic hemobilia documented by retrograde endoscopic cholangiography and treated by right hepatic artery ligation, is described. The role of ERCP in making the diagnosis of traumatic hemobilia is discussed.
Colonoscopy has added a new dimension to the diagnosis of colonic diseases. In the field of inflammatory bowel disease, colonscopy is indicated only when certain specific problems arise. Patients with acute colitis and those who are too sick to withstand cleansing enemas should not undergo colonoscopy. A major use of the colonoscope is in the detection of carcinoma in the colitic colon either in the form of colonic strictures or filling defects discovered by barium enema x-ray, or in the long-term surveillance of patients with universal ulcerative colitis. Criteria are listed to assist in the colonoscopic differential diagnosis between ulcerative and granulomatous colitis. By using different criteria than the radiographer, and with the help of biopsy specimens, a high degree of accuracy in proper diagnosis can be achieved.
We studied 258 patients with rectal bleeding and 46 patients with anemia and occult blood in the stool. All 304 patients had negative proctosigmoidoscopies, single-contrast barium studies that were negative or showed diverticula only, and colonoscopic evaluation. In the 258 patients, the overall incidence of finding significant lesions by colonoscopy was 41.5%. Twenty-nine patients (11.2%) had carcinoma and 17 patients (6.6%) had cecal telangiectasia. In the 46 patients, the overall incidence of finding significant lesions was 19.6%. Three patients with carcinoma were found in this group. A significant number of both benign and malignant lesions were detected by colonoscopy proximal to the splenic flexure. Colonoscopy should be done in patients with rectal bleeding or anemia and occult blood in the stool who have had negative proctosigmoidoscopies and single-contrast barium studies interpreted as normal or showing diverticula.
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Fifty-two patients with or without pancreatic disease were studied with both secretin test and endoscopic retrograde pancreatography. Pancreatic histopathology was obtained by exploratory laparotomy in half of these patients. The following conclusions were reached: 1. Secretory tests are the most sensitive indicators of chronic pancreatitis, although not all cases of chronic pancreatitis will be discovered by this test. 2. When secretory tests show low volume output, pancreatography is crucial in differentiating between malignant ductal obstruction or pancreatic replacement by fibrosis or atrophy. 3. Histologic correlation with ductular structure and/or secretin function is frequently discordant. 4. The secretin test and pancreatogram measure different parameters and the use of both these complementary studies will lead to increased diagnostic accuracy and better understanding of pancreatic pathophysiology.
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Carcinoma of the colon usually starts as a small nidus of malignant cells on the tip of adenomatous/villous polyps. The term "early cancer of the colon" is introduced as part of the concept that there are stages in the development of colon cancer and that it can and should be treated at an early stage. Removal of polyps at any point in their development up to the stage of early invasiveness represents the most favorable time for resection and cure.
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Diverticular disease comprises a spectrum of illness beginning with the irritable bowel syndrome and progressing to the life-threatening complications of diverticulitis and hemorrhage. Step-wise progression of this disease may be seen but is not invariably present; many patients with diverticulosis do not have preceding symptoms of the irritable bowel syndrome. The typical complaints of irregularity of bowel habits and abdominal pain will usually respond to the relatively new treatment modality of a high fiber diet with added wheat bran. Barium enema x-ray examination remains the primary diagnostic modality in the investigation of diverticular disease, and colonoscopy should be used only in the presence of certain specific circumstances. Surgery, aimed at the treatment of complications of this disease, has progressed to the point where one-stage extirpation of the diseased bowel is recommended.
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