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M B Fennerty

Publications and source records attributed to M B Fennerty.

At least 55 records · Page 3Linked to original sources
PubMed1999

A randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin videoendoscope.

BACKGROUND: Potential advantages of unsedated endoscopy include the prevention of side effects or morbidity related to the use of sedative drugs, less intensive patient monitoring, and less expense. We compared transnasal (T-EGD) with peroral (P-EGD) unsedated endoscopy by using an ultrathin video instrument with respect to patient tolerance and acceptance. METHOD: Patients were randomized to T-EGD or P-EGD. If the initial route of insertion failed, the patient was crossed over to the other route. If this also failed, the patient underwent endoscopy under conscious sedation with an ultrathin instrument. A questionnaire for tolerance was completed by the patient (a validated 0-10 scale where "0" represents none/well tolerated and "10" represents severe/poorly tolerated). RESULTS: Of 105 recruited patients, 60 consented to undergo unsedated endoscopy. There were 20 men and 11 women (mean age 45 years) in the P-EGD group and 15 men and 14 women (mean age 48 years) in the T-EGD group. Of 35 total P-EGD patients (4 were crossed over T-EGD patients), 34 (97%) completed an unsedated examination. Of 29 T-EGD patients, 25 (86%) had a complete examination. Three T-EGD examinations failed for anatomical reasons; all 3 patients when crossed over to the P-EGD route had a successful examination. One patient was unable to tolerate either route. Between the P-EGD and the T-EGD groups, pre-procedure anxiety (3.6 +/- 0.5 vs. 3.0 +/- 0.6), discomfort during insertion (2.1 +/- 0.5 vs 3.3 +/- 0.7), gagging (4.7 +/- 0.5 vs. 3.2 +/- 0. 6), and overall tolerance (2.4 +/- 0.5 vs. 3.8 +/- 0.7) were similar (p > 0.05). However, discomfort on insertion was significantly greater in the T-EGD versus the P-EGD group (4.4 +/- 0.6 vs. 2.7 +/- 0.5: p < 0. 05). Eighty-nine percent of P-EGD patients and 69% of T-EGD patients, p = 0.07, were willing to undergo unsedated endoscopy in the future. CONCLUSION: T-EGD patients experienced significantly more pain on insertion than did P-EGD patients. Otherwise, unsedated endoscopy by either the transnasal or the peroral route is generally well tolerated. In this study it was completed in 59 of 60 patients.

Adult↗
PubMed1999

Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study. The Multicenter Endoscopic Sphincterotomy (MESH) Study Group.

BACKGROUND: Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications. METHODS: A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization. RESULTS: Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours. CONCLUSIONS: Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission.

Adult↗
PubMed1999

Extraesophageal gastroesophageal reflux disease. Presentations and approach to treatment.

Prevalence of gastroesophageal reflux disease (GERD) is common in the adult US population, but likely is underestimated as many patients present with symptoms other than heartburn or regurgitation. Ears, nose, throat, pulmonary, and cardiac symptoms also frequently are related to GERD. The diagnosis of GERD as a cause of these symptoms can be difficult and treatment strategies are much less clear than in patients presenting with heartburn or regurgitation. This article discusses the epidemiology, pathogenesis, diagnosis, and treatment of some of the manifestations of extraesophageal reflux disease.

Asthma↗
PubMed1999

Eradication of Helicobacter pylori infection after ranitidine bismuth citrate, metronidazole and tetracycline for 7 or 10 days.

BACKGROUND: We assessed the efficacy, tolerance, and compliance of twice-daily triple therapy for Helicobacter pylori with ranitidine bismuth citrate, metronidazole and tetracycline for 7 or 10 days. METHODS: 105 subjects with H. pylori infection documented by the 13C-urea breath test were randomly assigned to a 7 or 10-day course of ranitidine bismuth citrate 400 mg b.d., metronidazole 500 mg b.d. and tetracycline 500 mg b.d. Subjects returned at the end of therapy for assessment of side-effects and pill count. A repeat 13C-urea breath test was obtained 4 or more weeks after completion of therapy and cure of infection was defined as a negative test result. RESULTS: Poor compliance (< 80% of medications) was seen in 2% of subjects randomized to 7 days of therapy and in 10% randomized to 10 days of therapy (P = N.S.). Intention-to-treat eradication rates were 56% for 7-day and 60% for 10-day therapy (P = N.S.). Per protocol eradication rates were 58% for 7-day and 61% for 10-day therapy (P = N.S.). The 10-day intention-to-treat eradication rate for males was 78% and 32% for females (P < 0.01) and per protocol eradication rates were 79% and 31%, respectively (P < 0.01). CONCLUSIONS: Despite excellent compliance and tolerance, neither 7 nor 10 days of therapy with twice-daily ranitidine bismuth citrate, metronidazole and tetracycline are adequate as a treatment of H. pylori infection.

Adult↗
PubMed1999

Correlation of ambulatory 24-hour esophageal pH monitoring results with symptom improvement in patients with noncardiac chest pain due to gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) accounts for up to 60% of patients with noncardiac chest pain (NCCP). Twenty-four-hour esophageal pH monitoring has been considered the most sensitive test for identifying acid reflux as the probable cause for chest pain. It is unclear if there is a correlation between the degree of esophageal acid exposure as determined by 24-hour esophageal pH monitoring and symptom improvement during a short course of high-dose omeprazole (the omeprazole test) in patients with NCCP due to GERD. Twenty-three patients with GERD-related NCCP were studied. All patients were referred by a cardiologist and evaluated by upper endoscopy and 24-hour esophageal pH monitoring. Diagnosis of GERD was defined by one or both tests being abnormal. Subsequently, patients underwent baseline symptom intensity assessment during 1 week off therapy followed by 1 week on therapy with high-dose omeprazole (40 mg A.M. and 20 mg P.M.). There was a statistically significant correlation between the esophageal acid exposure by 24-hour esophageal pH monitoring and the change in symptom intensity score after treatment. However, there was no significant correlation between the pH values and symptom intensity score during baseline or during the omeprazole test. In patients with GERD-related NCCP undergoing the omeprazole test, 24-hour esophageal pH monitoring has a therapeutic predictive value in addition to its diagnostic merit. Patients with greater esophageal acid exposure appear to have a greater response to antireflux treatment.

Anti-Ulcer Agents↗
PubMed1999

High- versus standard-dose ranitidine for control of heartburn in poorly responsive acid reflux disease: a prospective, controlled trial.

OBJECTIVE: H2-receptor antagonists are commonly used as initial therapy in patients with gastroesophageal reflux disease (GERD) and are frequently continued at the same or higher doses when symptoms persist after 4-6 wk of therapy. Our objective was to compare the efficacy of twice-daily treatment with either ranitidine 150 mg b.i.d. or 300 mg b.i.d. in resolving heartburn in GERD patients who remained symptomatic after 6 wk of therapy with ranitidine 150 mg b.i.d. METHODS: This was a two-phase, prospective study. In the first phase, GERD patients with heartburn on > or = 4 of the 7 days before entry were treated with open-label ranitidine 150 mg b.i.d. for 6 wk. In the second phase, patients who were still symptomatic were randomized to 8 wk of double-blind ranitidine therapy at either the same (150 mg b.i.d.) or a higher dose (300 mg b.i.d.). The primary efficacy variable was the resolution of heartburn at wk 4 and 8, as monitored through diary cards. RESULTS: Of the 481 patients treated for 6 wk in phase I, 285 (59%) were still symptomatic; 271 patients (95% of those still symptomatic) were randomized to double-blind treatment with ranitidine. In phase II, 45% of the patients in each treatment group experienced no more than mild heartburn; complete heartburn resolution was observed in <20% of patients in either group at wk 4 and 8. There were no significant differences in efficacy between the two treatment groups. CONCLUSIONS: These results indicate that the majority of GERD patients still have symptoms of heartburn after 6 wk of ranitidine therapy. Only a minority of these patients experience complete relief of heartburn after an additional 8 wk of treatment, which demonstrates that doubling the dose of ranitidine is not efficacious.

Adult↗
PubMed1999

Fingerstick Helicobacter pylori antibody test: better than laboratory serological testing?

OBJECTIVE: Antibody testing is the recommended method to screen for Helicobacter pylori (H. pylori) infection. Whole-blood fingerstick antibody tests are simple, in-office tests providing rapid results, but the accuracy of first-generation tests was lower than other diagnostic tests. We assessed a new whole-blood antibody test, using endoscopic biopsy tests as a "gold standard," and compared it with a laboratory quantitative serological test. METHODS: Two hundred-one patients not previously treated for H. pylori who were undergoing endoscopy had gastric biopsies for rapid urease test and histological examination; whole-blood antibody tests and quantitative serological tests were also performed. Two separate gold standards for H. pylori infection were employed: either rapid urease test or histological exam positive; and both rapid urease test and histological exam positive. RESULTS: Sensitivities for whole-blood test versus quantitative serology with gold standard 1 (either biopsy test positive) were 86% versus 92% (95% confidence interval [CI] of difference, -2-14%; p = 0.19) and specificities were 88% versus 77% (95% CI of difference, 0.4-22%; p = 0.052). Sensitivities with gold standard 2 (both biopsy tests positive) were 90% versus 94% (95% CI of difference, -4-12%; p = 0.41) and specificities were 79% versus 67% (95% CI of difference, 1-24%; p = 0.048). CONCLUSIONS: New generation in-office, whole-blood antibody tests that can achieve a sensitivity and specificity similar to or better than those of widely used quantitative laboratory serological tests may be used as the initial screening tests of choice for H. pylori.

Adult↗
PubMed1999

Tissue staining (chromoscopy) of the gastrointestinal tract.

Tissue staining, or chomoscopy, is used as an adjunctive technique during gastrointestinal endoscopy. Chemical agents are applied to the gastrointestinal mucosal surface to identify specific epithelia or to enhance the mucosal surface characteristics of the gastrointestinal epithelium. This aids in the recognition of subtle lesions (ie, polyps) or allows directed targeting of biopsies (ie, sprue or Barrett's esophagus) to increase the yield of endoscopic diagnostic accuracy. The four endoscopic tissue-staining techniques in use are vital staining, contrast staining (chromoscopy), reactive staining and tattooing. Some of the agents used for endoscopic tissue staining and the uses of chromoscopy in identifying pathology of the esophagus, stomach, small bowel and colon during endoscopy are discussed.

Biopsy, Needle↗
PubMed1998

Effect of proton-pump inhibitor therapy on diagnostic testing for Helicobacter pylori.

BACKGROUND: Proton-pump inhibitor therapy may cause false-negative results on Helicobacter pylori diagnostic testing. OBJECTIVE: To determine the frequency and duration of conversion of urea breath test results from positive to negative in patients given a proton-pump inhibitor. SETTING: Two urban university gastroenterology clinics. PATIENTS: Patients infected with H. pylori who had positive results on urea breath tests. INTERVENTION: Lansoprazole, 30 mg/d for 28 days. MEASUREMENTS: The urea breath test was repeated at 28 days. If the results were negative, testing was repeated 3, 7, 14, and 28 days after completion of therapy until the results reverted to positive. RESULTS: 31 (33%) of 93 patients in whom H. pylori was not eradicated had a negative breath test result while receiving lansoprazole. The proportions of patients whose breath test results were positive after completion of lansoprazole therapy were 91% (95% CI, 83% to 96%) at 3 days, 97% (CI, 90% to 99%) at 7 days, and 100% (CI, 96% to 100%) at 14 days. CONCLUSION: Patients should not receive proton-pump inhibitors for 2 weeks before receiving the urea breath test for H. pylori infection.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed1998

The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain.

BACKGROUND & AIMS: Evaluation of new patients with noncardiac chest pain (NCCP) may require a variety of costly tests. The aim of this study was to evaluate the efficacy of the omeprazole test (OT) in diagnosing gastroesophageal reflux (GERD) in patients with NCCP and estimate the potential cost savings of this strategy compared with conventional diagnostic evaluations. METHODS: Thirty-nine patients referred by cardiologists were enrolled. Baseline symptoms were recorded, and the patients were randomized to either placebo or omeprazole (40 mg AM and 20 mg PM) groups for 7 days. Patients were crossed over to the other arm after a washout period and repeat baseline symptom assessment. All patients underwent 24-hour esophageal pH monitoring and upper endoscopy before randomization. RESULTS: Thirty-seven patients (94.9%) completed the study. Twenty-three (62.2%) were classified as GERD positive and 14 as GERD negative. Eighteen (78%) GERD-positive patients and 2 (14%) GERD-negative patients had a positive OT (P < 0.01), yielding a sensitivity of 78.3% (95% confidence interval, 61.4-95.1) and specificity of 85.7% (95% confidence interval, 67.4-100). Economic analysis showed that the OT saves $573 per average patient evaluated and results in a 59% reduction in the number of diagnostic procedures. CONCLUSIONS: The OT is sensitive and specific for diagnosing GERD in patients with NCCP. This strategy results in significant cost savings and decreased use of diagnostic tests.

Adult↗
PubMed1998

Noninvasive diagnosis of gastroesophageal inflammation using dipyridamole thallium-201 tomography.

OBJECTIVE: Esophagitis, a complication of GERD, and gastric erosions are common findings in dyspeptic patients. Unfortunately, these findings cannot be predicted based on symptoms alone and require endoscopy for an accurate diagnosis. Noninvasive diagnosis of other gastrointestinal pathology by radiopharmaceuticals (GA 67, Tc 99m pertechnetate) has previously been studied. We hypothesized that endoscopically documented esophagitis and/or gastric erosions could also be detected by using dipyridamole thallium-201 imaging and, if they were of sufficient accuracy, could serve as a useful, noninvasive screening test for esophagitis and/or gastric erosions. METHODS: A pilot study was undertaken in 12 patients undergoing endoscopy for symptoms of GERD or dyspepsia. Esophagitis was defined as the presence of either erosions or ulceration and gastric erosions were defined as discrete mucosal breaks measuring > or = 1 mm. Dipyridamole thallium-201 imaging was performed the following day on all 12 patients. A standard dose of dipyridamole (0.56 mg/kg) was infused over 4 min, followed by a 3-mCi dose of thallium-201. Initial stress tomographic images and reinjection (1 mCi) resting tomographic images 3-4 h later were obtained using a gamma camera. Tomographic images were read blinded to the endoscopy results. Thallium-201 uptake was graded on a 0-3+ scale using the liver uptake as the internal comparative standard (2+ = uptake equal to the liver). Abnormal thallium uptake was defined as > or = 2+ in the area of the esophagus or stomach. RESULTS: Seven women and five men (mean age 41 yr, range 25-60 yr) were studied. Eight patients were taking histamine-2 receptor antagonists and none were on proton pump inhibitors, or promotility agents. All five patients with endoscopic esophagitis had a positive thallium-201 tomographic image. Seven patients had no evidence of esophagitis, and three had positive thallium-201 tomograms. Dipyridamole thallium-201 imaging sensitivity, specificity, and positive and negative predictive values for esophagitis were 100%, 57%, 63%, and 100%, respectively. All three patients with gastric erosions had positive thallium-201 tomograms. Six of nine patients without gastric erosions had positive tomograms. The sensitivity, specificity, and positive and negative predictive values of DT 201 gastric erosions were 100%, 33%, 33%, and 100%, respectively. CONCLUSIONS: Dipyridamole thallium-201 tomographic imaging has good sensitivity (100%) in detecting esophagogastric mucosal erosions, but its poor specificity (33-57%) results in an unacceptable accuracy as a screening test. Additionally, the cost of radiopharmaceuticals requires that sensitivity and specificity be at least equal to that of endoscopy for this test to be clinically valuable as a screening test. However, a noninvasive test for these diseases is inherently appealing, and further research in this area seems to be warranted.

Adult↗
PubMed1998

Biopsy-negative malignant esophageal stricture: diagnosis by endoscopic ultrasound.

Endoscopic ultrasound (EUS) of the esophagus has been used primarily in staging biopsy-proven cancers. Its use as a primary diagnostic modality for esophageal malignancy has not been previously described. We report our recent experience in four patients with dysphagia and endoscopic biopsies negative for malignancy, including one patient with clinical and manometric features suggestive of achalasia. In all cases, EUS revealed a large infiltrating tumor invading through the esophageal wall into the surrounding tissues, and in one case into the aorta. Computed tomography suggested the possibility of a tumor in only one of the cases. Two patients underwent esophagectomy and were found to have adenocarcinoma. Two patients underwent repeat biopsy with alternative aggressive biopsy techniques and were found to have squamous cell carcinoma. We conclude that EUS is useful in the diagnosis of esophageal cancer and should be performed in selected patients with esophageal strictures whose biopsies are negative for malignancy; i.e., those with suspicious endoscopic or radiographic appearance, atypical presentation (e.g., profound weight loss, short duration of symptoms, or advanced age), and failure to respond to treatment.

Adenocarcinoma↗
PubMed1997

What are the treatment goals for Helicobacter pylori infection?

The goals of therapy of Helicobacter pylori are commonly viewed as either clinical (e.g., avoid further morbidity, mortality, or prevent disease from occurring) or economic (e.g., save healthcare dollars by avoiding further expenditure of resources). However, when viewed globally, these goals are not incongruent but are inexorably linked. Prevention of disease or avoidance of further morbidity and mortality by curing H. pylori infection is obviously an improved clinical outcome, but it also concurrently avoids further utilization of healthcare resources and is "cost-effective," resulting in improved economic outcome as well. The more clinically effective an H. pylori treatment is, the more economically effective it is as well. When comparing regimens, the cost-effectiveness is determined by efficacy of the regimen, not its cost. Put more simply, "The most expensive therapy is the one that doesn't work!" Therefore, the goals of the therapy are simple: avoid further morbidity, mortality, and prevent disease while minimizing further utilization of healthcare resources, thus saving money. The most clinically effective therapy is also the most cost-effective therapy. Regimens used should have demonstrated greater than 90% efficacy or effectiveness in the population being treated for H. pylori infection. The regimens should be simple and well tolerated. It is clinically and economically inappropriate to use a regimen not meeting these criteria.

Gastroenterology↗
PubMed1997

Academic medicine under managed care.

Academic gastroenterology is at a crossroads. If academic gastroenterologists are to survive and thrive in this era of managed care, they must develop innovative means of funding teaching and research. This funding can be accomplished while adapting to and embracing managed care. Academic gastroenterologists need to work closely with managed care in developing novel means of training fellows and focusing research on outcomes (both clinical and economic). At the same time, academic gastroenterologists have to compete in the marketplace for patient care revenue as a funding source. This competition requires a concerted effort to improve efficiency in academic practice and is likely to result in less time devoted exclusively to research and teaching. Increased clinical practice can also result in enhanced clinical research opportunities, however, as well as an ability to expand teaching in an ambulatory setting. It is clear that managed care will not adapt to academic gastroenterologists. If academic gastroenterologists are to maintain their preeminence in medical education and research, they must adapt to a managed care world.

Academic Medical Centers↗