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Biomedical subjects

M B Fennerty

Publications and source records attributed to M B Fennerty.

At least 73 records · Page 4Linked to original sources
PubMed1997

Yield of routine endoscopy beyond the duodenal bulb.

The authors determined the clinical yield, endoscopic time, and patient tolerance of routine upper endoscopy beyond the duodenal bulb. From May through October 1994, all patients undergoing routine esophagogastroduodenoscopy (EGD) were recruited for study. Each procedure was timed from start to finish by the endoscopy nurse, and, in addition, the time of the postbulbar examination was recorded. The endoscopy nurse assessed the patient's comfort level when the endoscope was advanced into the duodenal bulb and again at the postbulbar region. A total of 250 EGDs were performed. There were 152 males and 98 females, with a mean age of 57.1 (range, 23-91) years. Indications for the procedure were as follows: gastroesophageal reflux disease symptoms 82, epigastric pain 64, dysphagia 46, Barrett's surveillance 25, anemia 23, other research study 16, and other 61. The mean time for the procedure was 11 min and 54 s, whereas the mean time for the postbulbar examination was 46.6 s. Patients tolerated endoscope insertion well both before and during examination of the postbulbar duodenum. The only postbulbar finding that affected clinical management was a postbulbar ulcer in a patient without other ulcers who was positive for Helicobacter pylori. Although routine endoscopic examination beyond the duodenal bulb involves minimal time and is well tolerated by patients, the yield of pathologic findings is low (3.6%) and the yield of findings that alter clinical management even lower (0.4%). In patients without prior GI surgery undergoing routine EGD for indications other than suspected small bowel pathology or active upper GI bleeding, examination of the postbulbar duodenum can be considered an elective part of the procedure.

Adult↗
PubMed1997

Medical treatment of gastroesophageal reflux disease in the managed care environment.

The goals of management of any disease process (ie, to relieve symptoms, heal the process, and prevent complications while minimizing the use of health care resources), including gastroesophageal reflux disease (GERD), are not altered by practicing within a managed care environment. However, short-sightedness sometimes leads one to view outcomes from a narrow focus (costs of treatments, diagnostic tests, etc) instead of evaluating overall cost and outcome. GERD is an example in which short-sighted approaches (using cheaper but less effective pharmaceutical agents) have led to worse outcomes and more costly therapy. A therapy that is less costly but also less effective in preventing symptoms and complications is more expensive than a therapy that costs more but keeps a patient in remission. "The most expensive therapy is the one that doesn't work." These simple, underutilized, pharmacoeconomic concepts are the basis for the discussion of GERD and the suggested treatment algorithm that follows.

Algorithms↗
PubMed1997

Marking and identifying colon lesions. Tattoos, clips, and radiology in imaging the colon.

Precise knowledge of a lesion's location in the colon is infrequently required. Occasionally, however, this information can be of critical clinical importance. A variety of endoscopic and radiologic techniques have been described to localize an area or site within the colon. Tissue staining or tattooing is the most reliable endoscopic method of colon lesion localization, and India ink provides a long-lasting and probably permanent tattoo of the site. Endoscopic clips are less reliable and remain cumbersome to use. Electronic imaging is an intriguing approach but remains experimental. Sites and lesions also can be identified by barium radiography or fluoroscopy, but these techniques involve added expenses and are not as reliable as tattooing with India ink.

Barium Sulfate↗
PubMed1997

Lack of spontaneous regression of tubular adenomas in two years of follow-up.

OBJECTIVE: Change in colon polyp size over time has not been well characterized. It has been inferred that some polyps will increase in size, leading to an increased risk of progressing to cancer, whereas other polyps may spontaneously regress. To develop a better understanding of the natural history of colon polyps, we prospectively investigated change in polyp size over a 2-yr period. METHODS: Patients were enrolled if they had an endoscopically detected proximal rectal or sigmoid polyp measuring 3-9 mm. The index polyp site was then permanently marked with an adjacent India ink tattoo to allow definitive future localization of the polyp. Patients underwent flexible sigmoidoscopy at 6-month intervals, and at each examination, the polyp size was carefully measured with open biopsy forceps. After a maximum of 2 yr, each polyp was removed and the histology determined. RESULTS: Thirty polyps were followed in 26 patients who completed the study. Twelve polyps were tubular adenomas (TA), one was tubulovillous, 14 were hyperplastic polyps (HP), two had no pathological diagnosis, and one was a leiomyoma. HP were more likely to decrease in size than were TA. Three polyps demonstrated fast growth rates (2-4 mm/yr), and all were TA. Two polyps were removed early because their size had reached 1 cm or more. Both of those polyps were TA. No polyps regressed completely during the 2 yr of the study; neither did we find consistent linear growth rates. CONCLUSIONS: In contrast to prior reports, in this study, after polyps had been definitively localized with India ink, we observed no complete polyp regressions.

Adenoma↗
PubMed1996

Complications of endoscopic biliary sphincterotomy.

BACKGROUND: Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. METHODS: We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. RESULTS: Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01). CONCLUSIONS: The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.

Age Factors↗
PubMed1996

The diagnosis and treatment of gastroesophageal reflux disease in a managed care environment, Suggested disease management guidelines.

A group of experts from gastroenterology, internal medicine, health economics, medical outcomes, and managed care met in San Francisco, Calif, on September 27, 1994, in an effort to develop clinically and economically effective disease management guidelines to assist physicians in their treatment of gastroesophageal reflux disease in a managed care environment. This article represents a consensus opinion based on the evidence and expert interpretation at the time of that meeting.

Algorithms↗
PubMed1996

The difference in colon polyp size before and after removal.

BACKGROUND: Accurate knowledge of polyp size is important in assessing cancer risk in both clinical studies and individual patients. We sought to determine if a difference exists between the endoscopic estimation of colon polyp size and the actual measurement after removal. METHODS: We measured polyps in a systematic fashion. Using open biopsy forceps as a guide, the largest diameter of 31 pedunculated polyps was estimated endoscopically. The polyp was then removed by snare polypectomy and directly measured by a technician who was blinded to the endoscopic estimate. Each polyp was also measured after formalin fixation by a pathologist who was blinded to previous measurements. RESULTS: There was a significant difference between the endoscopic estimates and the postpolypectomy measurements. Endoscopic estimates on average were 1.6 mm greater than the postpolypectomy measurements (p< 0.05), representing an 18% difference. Twenty-three of the 31 (74%) endoscopic estimates were larger than the postpolypectomy measurements. There was not a significant difference between the postpolypectomy and postfixation measurements. CONCLUSIONS: The size of polyps measured endoscopically is significantly larger on average than postpolypectomy measurements. This is most likely due to factors involved in the removal of the in vivo polyp.

Adult↗
PubMed1996

Cost-effectiveness of treatment regimens for the eradication of Helicobacter pylori in duodenal ulcer.

BACKGROUND: Eradication of Helicobacter pylori with antimicrobials was recommended by a recent NIH consensus panel for all infected patients with peptic ulcer disease. The precise regimen that should be used for eradication of the infection remains uncertain because of the variety of regimens described, variable results with the regimens, and difficulties in predicting drug compliance outside clinical trials. METHODS: A decision analysis tree was developed with three regimens that are widely used regimens for the eradication of H. pylori: 1) 2-wk triple drug therapy (metronidazole, bismuth, tetracycline with H2 receptor antagonist), 2) 2-wk omeprazole and amoxicillin, and 3) 2-wk omeprazole and clarithromycin. Traditional H2 receptor antagonist therapy was used for comparison. A 2-yr time period was chosen for study to allow sufficient time for relapse and to evaluate its effect on the treatment strategy. Probabilities for eradication, compliance, and metronidazole resistance were determined from published data, and assumptions were tested by sensitivity analysis. RESULTS: Standard 2-wk triple drug therapy was the least expensive strategy ($720), and conventional H2 receptor antagonist therapy was the most expensive ($1791). Costs with 2-wk therapy with omeprazole and clarithromycin ($768) were lower than with omeprazole and amoxicillin ($1028). CONCLUSIONS: Treatment to eradicate H. pylori in infected patients with duodenal ulcer is a less expensive strategy than traditional therapy with H2 receptor antagonists. Triple drug therapy is the optimal regimen in areas where metronidazole resistance rates are < 36% and compliance is > 53%. Omeprazole and amoxicillin is not cost-effective unless eradication rates are greater than 74%. Dual drug therapy with omeprazole and clarithromycin is effective in regions where metronidazole resistance is high or where it is anticipated that there would be poor compliance with the more complicated triple drug therapy regimen.

Amoxicillin↗
PubMed1996

Gastric malignancy.

Gastric cancer remains a clinically important tumor. Changing demographics, the association with Helicobacter pylori infection, and the fact that gastric carcinoma remains the world's second most common malignancy all have rekindled interest in this tumor, resulting in numerous studies attempting to define patterns, associations, and causes. This article focuses on new data regarding this malignancy, especially as it impacts on the endoscopic approach to diagnosis and therapy.

Gastroscopy↗