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Biomedical subjects

M S Cappell

Publications and source records attributed to M S Cappell.

At least 37 records · Page 2Linked to original sources
PubMed1996

A study at 10 medical centers of the safety and efficacy of 48 flexible sigmoidoscopies and 8 colonoscopies during pregnancy with follow-up of fetal outcome and with comparison to control groups.

To analyze the risks versus benefits of flexible sigmoidoscopy and colonoscopy to the pregnant female and fetus, we conducted a multiyear, retrospective study at 10 hospitals of 46 patients undergoing 48 sigmoidoscopies and 8 patients undergoing 8 colonoscopies during pregnancy. Sigmoidoscopy controls included two study control groups and the average American pregnancy outcomes. Sigmoidoscopy indications included hematochezia in 28, diarrhea in 10, abdominal pain in 4, and other in 3. Thirteen patients were in the first trimester of pregnancy, 18 were in the second trimester, and 15 were in the third trimester. Twenty-seven patients had a lesion diagnosed by sigmoidoscopy, including reactivated or newly diagnosed inflammatory bowel disease, bleeding internal hemorrhoids, and other colitidies. Twenty-two of 29 patients with rectal bleeding had a significant lesion identified by sigmoidoscopy. Sigmoidoscopy was significantly more frequently diagnostic for hematochezia than for other indications (p < 0.03, chi2). No endoscopic complications occurred to the pregnant patients. Excluding 4 voluntary abortions and 1 unknown pregnancy outcome, 38 (93%) of 41 pregnant females delivered healthy babies (study control rate = 93%; NS, Fisher's exact test). Mean live-born infant Apgar scores were 8.2+/-1.5 (SD) at 1 min and 9.0+/-0.2 at 5 min (control mean Apgar scores: 8.1+/-1.7 at 1 min and 8.8+/-1.0 at 5 min; NS, Student's t test). Three high-risk pregnancies ended with fetal demise at 8, 9, or 12 weeks after sigmoidoscopy, from causes unrelated to sigmoidoscopy. No fetal cardiac abnormalities were detected by fetal cardiac monitoring during two sigmoidoscopies. Eight pregnant females underwent colonoscopy, without complications. Pregnancy outcomes included six healthy babies delivered at full term, one voluntary abortion, and one fetal demise in a high-risk pregnancy 4 months after colonoscopy from causes unrelated to colonoscopy. This study suggests that sigmoidoscopy does not induce labor or result in congenital malformations, that sigmoidoscopy is not contraindicated during pregnancy, and that sigmoidoscopy may be beneficial in pregnant patients with significant lower gastrointestinal bleeding. Colonoscopy during pregnancy should be considered for life-threatening lower gastrointestinal bleeding or when the only alternative is surgery.

Colonoscopy↗
PubMed1996

A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with follow-up of fetal outcome with comparison control groups.

OBJECTIVES: To analyze risks versus benefits of esophagogastroduodenoscopy (EGD) during pregnancy to the fetus and pregnant female. METHODS: Retrospective study of 83 consecutive pregnant patients who underwent EGD admitted to eight university teaching hospitals during a study period of up to 14 yr, with follow-up of fetal outcome. Controls included: 48 pregnant females matched for EGD indications who did not undergo EGD (pregnant controls), 83 nonpregnant females undergoing EGD matched for age and EGD indication (EGD controls), and national pregnancy outcome rates (national controls). RESULTS: EGD indications included acute GI bleeding in 37, vomiting and abdominal pain in 17, vomiting in 14, abdominal pain in 11, and other in four. The mean week of gestation was 19.8 +/ 8.9 EGD was diagnostic in 65 patients. The diagnostic yield of EGD was 95% for acute GI bleeding and ranged from 50 to 82% for the other indications (significantly different rates, odds ratio = 9.3, p < 0.001, odds ratio confidence interval = 2.22-45.5). Esophagitis was found in 62+ of patients with a diagnostic EGD. No significant endoscopic complications occurred. EGD did not induce labor. Excluding six voluntary abortions and three unknown pregnancy outcomes, 70 (95%) of 74 patients delivered healthy babies (pregnant control rate = 94%, national control rate = 98.4%, all not significant, Fisher's exact test). Moreover, the four poor outcomes (three stillbirths and one involuntary abortion) occurred in high risk pregnancies and were unrelated to EGD temporally or etiologically. No other infant had a congenital malformation noted in the neonatal nursery. Nine (12.7%) of the live born infants had a low birth weight (pregnant control rate = 8.5%, national control rate = 7.0%, all not significant, kappa 2). Mean Apgar scores of live born infants were 7.7 +/ 1.6 at 1 min and 9.0 +/ 0.6 at 5 min (pregnant control scores = 7.6 +/ 2.0 at 1 min and 8.5 +/ 1.1 at 5 min; national control mean scores = 8.0 +/ 1.4 at 1 min and 9.0 +/ 0.9 at 5 min; all not significant, Student's t test). In three cases with fetal cardiac monitoring, EGD did not induce abnormal fetal heart rates (preendoscopy rate = 143.3 +/ 5.8 beats/min, postendoscopy rate = 148.0 +/ 10.6 beats/min). CONCLUSIONS: In this study, EGD did not induce labor or result in congenital malformations. EGD is not contraindicated during pregnancy. EGD is beneficial in pregnant patients with upper GI bleeding.

Abdominal Pain↗
PubMed1996

The safety and efficacy of percutaneous endoscopic gastrostomy after recent myocardial infarction: a study of 28 patients and 40 controls at four university teaching hospitals.

OBJECTIVES: To analyze the risks versus benefits of percutaneous endoscopic gastrostomy (PEG) performed soon after myocardial infarction. METHODS: Retrospective review of 28 patients undergoing PEG within 30 days after myocardial infarction at four university teaching hospitals for study periods of up to 10 yr. Forty controls undergoing PEG were matched for age and sex and had no myocardial infarction during the prior 6 months. RESULTS: Indications for PEG were inability to eat because of stroke in 13, chronic dependency on mechanically assisted ventilation in seven, anoxic encephalopathy in five, dementia in two, and other in one. The mean patient age was 72.5 +/- 9.2 (SD) yr. PEG was performed on average 22.3 +/- 6.2 days after myocardial infarction. Seventeen patients were intubated and were receiving mechanically assisted ventilation at the time of PEG. PEG was successfully performed in all patients. Study patients suffered two insignificant complications, and one significant complication from PEG of bleeding at the gastrostomy site that required transfusion of 4 U of packed erythrocytes. Of note, no study patient suffered a cardiovascular complication due to PEG. The control complication rate was not significantly different (three insignificant and one significant complications, NS, Fisher's exact test). PEG feedings in study patients resulted in stabilization of body weight and significant improvement of the serum albumin level (from 2.2 +/- 0.3 gm/dl to 2.5 +/- 0.5 gm/dl, p < 0.03, Student's t test). Also the absolute lymphocyte count, hematocrit, and serum total protein level tended to improve after PEG. PEG contributed to transfer to a rehabilitation center, skilled nursing facility, or home in 19 study patients (70%; control rate = 78%, NS, chi 2). CONCLUSION: Recent myocardial infarction is not an absolute contraindication to PEG. In this study, the benefits exceeded the risks of PEG in medically stable patients. PEG should be performed with monitoring by electrocardiography and pulse oximetry in medically stable patients. PEG is an elective procedure that should not be performed in highly unstable patients.

Aged↗
PubMed1996

Endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy for symptomatic choledocholithiasis after recent myocardial infarction.

In the general population, endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is preferable to surgery as therapy for gallstone pancreatitis and acute cholangitis. It is particularly attractive to perform therapeutic. ERCP for symptomatic choledocholithiasis after recent myocardial infarction because of the increased risk of the alternative therapy of cholecystectomy and choledochal exploration. However, after myocardial infarction, patients might theoretically be particularly susceptible to the cardiopulmonary risks of ERCP. The safety of therapeutic ERCP after myocardial infarction is unknown, with only one previously reported case. In a review of 11,367 patients with acute myocardial infarction at four hospitals, four patients (0.04%) underwent therapeutic ERCP after recent myocardial infarction, for indications of recent biliary pancreatitis in three of the patients and recent cholangitis in all four. Cholangitis occurred before, simultaneous with, or after myocardial infarction in the four cases. Initially, the cholangitis was managed medically in three patients. The fourth patient underwent cholecystostomy with local anesthesia. ERCP was performed at 15, 25, 30, or 56 days after myocardial infarction. Endoscopic cholangiography revealed multiple choledocholithiasis in all cases. The calculi were successfully extracted by endoscopic papillotomy and by sweeping the choledochus with a balloon-tipped catheter or basket in all cases. During ERCP, the vital signs remained stable; no cardiac arrhythmias or cardiovascular complications occurred. However, one patient developed mild pancreatitis after ERCP, which rapidly resolved with medical therapy. The four patients rapidly improved after ERCP, with normalization of serum levels of routine biochemical parameters of liver function. These four cases and the one prior case report demonstrate that therapeutic ERCP is not absolutely contraindicated after myocardial infarction and suggest that therapeutic ERCP is preferable to surgery for symptomatic choledocholithiasis after myocardial infarction because of the increased mortality of surgery after myocardial infarction.

Aged↗
PubMed1995

Endoscopic, radiographic, and manometric findings associated with cardiovascular dysphagia.

The roentgenographic, echocardiographic, endoscopic, and manometric findings were studied in five consecutive patients with cardiovascular dysphagia, including four with a dilated left atrium and one with an anomalous left subclavian artery. Common and different manometric findings were found in the two types of cardiovascular dysphagia. The major manometric abnormality in all cases was an elevated baseline pressure, with superimposed large rhythmic pressure waves occurring at the same frequency as the electrocardiogram in the mid-esophagus. This manometric abnormality, produced by pulsatile cardiovascular compression, provides direct evidence that cardiovascular dysphagia is caused by esophageal luminal obstruction from cardiovascular compression. Indirect evidence supporting this mechanism includes smooth extrinsic compression and hang-up of ingested barium in the mid-esophagus on esophagogram and transmitted mural pulsations and a compressed lumen in the mid-esophagus at panendoscopy. Two of the five patients had deranged esophageal peristalsis within the high-pressure zone, which also contributed to the dysphagia. Autopsy in one patient with deranged peristalsis revealed a band of ischemic esophageal mucosa in the zone compressed by the dilated left atrium. A novel manometric maneuver might distinguish dysphagia due to an anomalous left subclavian artery from dysphagia due to a dilated left atrium. Left arm elevation during manometry in the single patient with the anomalous artery significantly increased the mean mid-esophageal baseline pressure by 92% (N = 10 trials), and mean pressure wave amplitude by 93% (N = 10 trials, P < 0.002 for each, nonparametric signed rank test). Left arm elevation in this patient also increased the observed luminal obstruction during endoscopy. These manometric and endoscopic findings may be explained by increased arterial compression of the esophagus produced by arterial stretch and anterior displacement with arm elevation.

Adult↗
PubMed1995

Increased mortality of acute upper gastrointestinal bleeding in patients with chronic obstructive pulmonary disease. A case controlled, multiyear study of 53 consecutive patients.

The etiology, clinical presentation, and mortality of acute upper gastrointestinal bleeding in patients with chronic obstructive pulmonary disease (COPD) were analyzed in a case-controlled study of 53 consecutive patients admitted from 1985 through 1990 to a university teaching hospital. The primary controls were 40 consecutive patients with acute upper gastrointestinal bleeding and without COPD admitted from June through November 1990 to the same hospital. COPD patients had a significantly increased mortality from gastrointestinal bleeding as compared to controls with gastrointestinal bleeding and without COPD (mortality in COPD = 32%, controls = 10%, odds ratio = 4.3, confidence interval of odds ratio = 1.22-14.8, P < 0.01, Fisher's exact test) and as compared to a second control group of 53 consecutive COPD patients without gastrointestinal bleeding (mortality in second controls = 11%, odds ratio = 3.7, confidence interval of odds ratio = 1.25-11.0, P < 0.02, chi square). The study COPD patients had a significantly greater likelihood of being older, smokers, alcoholics, and taking corticosteroids than the primary controls. However, an increased mortality was still present when controlling for these differences by population stratification (eg, mortality in patients > or = 60 years old: COPD = 36%, controls = 13%, odds ratio = 4.6, P < 0.05). The two groups had similar mean values of parameters of bleeding severity, such as lowest hematocrit and units of packed erythrocytes transfused. The increased mortality was correlated with COPD severity (eg, four of five patients with prior endotracheal intubation for COPD died, 13 of 48 COPD patients without prior intubation died, odds ratio = 10, P < 0.04, Fisher's exact test).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1995

Multicenter, multiyear study of safety and efficacy of flexible sigmoidoscopy during pregnancy in 24 females with follow-up of fetal outcome.

Our objectives were to analyze the risks versus benefits of flexible sigmoidoscopy to the pregnant female and fetus. We retrospectively studied 24 consecutive pregnant patients admitted to four university hospitals during seven years who underwent 26 flexible sigmoidoscopies. Sigmoidoscopy indications included hematochezia in 11, diarrhea in 12, abdominal pain in 7, constipation in 2, and occult rectal bleeding in 1. Seven patients were in the first trimester of pregnancy, nine were in the second trimester, and eight were in the third trimester. Sigmoidoscopy provided helpful clinical information in all patients. Twelve patients had a lesion diagnosed by sigmoidoscopy, including reactivation of Crohn's colitis, reactivation of ulcerative colitis, infectious colitis, nonspecific colitis, bleeding internal hemorrhoids, pseudomembranous colitis, anastomotic ulcer, and newly diagnosed Crohn's colitis. In particular, nine of 11 patients with rectal bleeding had a lesion identified by sigmoidoscopy. No endoscopic complications occurred to any pregnant female. Two pregnant patients underwent repeat sigmoidoscopy without complications. Fetal outcome was ascertained in all but one pregnancy. Eighteen pregnant females delivered healthy infants (16 at full term, two at 35 or 36 weeks). Their mean Apgar scores were 8.8 +/- 0.4 SD at 1 min, and 9.0 +/- 0.4 SD at 5 min. One diabetic and hypertensive female suffered an involuntary abortion nine weeks after sigmoidoscopy, which appeared unrelated to the sigmoidoscopy. Four pregnancies were voluntarily aborted. This study suggests that flexible sigmoidoscopy does not induce labor or result in congenital malformations, that sigmoidoscopy is not contraindicated during pregnancy, and that sigmoidoscopy should be considered in medically stable pregnant patients with significant gastrointestinal bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1995

Acute pancreatitis in HIV-seropositive patients: a case control study of 44 patients.

PURPOSE: To analyze whether pancreatitis presents differently in HIV-seropositive patients compared to the general population, and to evaluate the accuracy of classic predictors of pancreatitis severity in patients with HIV infection. METHODS: A multiyear, multicenter, retrospective study of 44 consecutive patients with acute pancreatitis and HIV and 44 consecutive control patients with acute pancreatitis without HIV. RESULTS: Of 939 hospitalized patients with HIV, 44 (4.7%) had acute pancreatitis, 27 of whom had AIDS. Pancreatitis presented with similar clinical findings in HIV patients and controls except that HIV patients had greater anemia, hypoalbuminemia, and leukopenia (Student's t-test P < 0.0001, < 0.0002, < 0.0001, respectively), and a higher incidence of fever, diarrhea, and hepatomegaly. These differences probably stem from HIV-related immunosuppression and malnourishment rather than pancreatitis. Patients with HIV had a higher frequency of medication-associated pancreatitis due to pancreatoxic medications used in HIV patients (18 versus 2 cases; odds ratio [OR] 14.54; Student's t-test P < 0.0001). They had a lower frequency of gallstone pancreatitis (2 versus 22 cases; OR 0.05; P < 0.0001). Patients with HIV had a higher frequency of a severe hospital course, defined as prolonged hospitalization or death in hospital (22 versus 12 cases; chi-square P < 0.05). The presence of AIDS or leukopenia in patients with HIV was strongly associated with a severe hospital course. The Ranson and modified Glasgow scales were poor predictors of disease severity in HIV patients (eg, Ranson scale sensitivity 41%; positive predictive value 53%; negative predictive value 52%). These scales' lack of markers of immunosuppression impeded their performance. The APACHE II scale, which contains markers of immunosuppression, was a moderately robust predictor of disease severity in HIV patients (sensitivity 73%; specificity 68%; positive predictive value 70%; negative predictive value 71%). All three scales predicted the disease severity in control patients well. CONCLUSIONS: Pancreatitis presents similarly in HIV patients as in the general population with the following significant differences: a high frequency of medication-associated pancreatitis, a low frequency of gallstone pancreatitis, a high frequency of HIV-related causes (most commonly from HIV-related drugs), additional symptoms and signs due to underlying immunosuppression, and a more severe hospital course. The APACHE II system can be used to predict whether a patient with HIV and pancreatitis is at risk for prolonged hospitalization or death in hospital.

AIDS-Related Opportunistic Infections↗
PubMed1995

A multicenter, multiyear, case-controlled study of the risk of colonic polyps in patients with gastric polyps. Are gastric adenomas a new indication for surveillance colonoscopy?

A multicenter, multiyear, case-controlled colonoscopic study of 41 patients with gastric polyps undergoing colonoscopy analyzed whether patients with gastric polyps, particularly adenomas, run an increased risk of having colonic polyps. The primary controls were 109 patients undergoing colonoscopy matched for age and colonoscopy indications. A secondary control group was 69 of these 109 patients who, in addition to matching for age and colonoscopy indications with study patients, had no gastric polyps demonstrated by upper gastrointestinal examination. Patients with nonmalignant mucosal gastric polyps had a significantly greater incidence than primary controls of colonic polyps [odds ratio (OR) = 3.19, OR confidence interval = 1.46 - 6.99, p < 0.004, chi(2)], colonic neoplasms (OR = 3.58, OR confidence interval = 1.56 - 8.23, p < 0.006, chi(2)), and colonic cancer (OR = 4.5, OR confidence interval = 1.05 - 19.4, p < 0.04, Fisher's exact test). Moreover, patients with gastric adenomas had a significantly greater incidence than did primary controls of colonic polyps (OR = 7.6, OR confidence interval = 1.29 - 44.7, p < 0.02, Fisher's exact test). The association between gastric and colonic polyps did not arise as an artifact of the significantly higher frequency of females in the study group because this association remained after patient stratification by sex. The higher risk of colonic polyps in study patients did not arise as an artifact of unappreciated gastric polyps in the primary controls because study patients also had a significantly higher risk of colonic polyps than the secondary controls (OR = 3.21, OR confidence interval = 1.35 - 7.63, p , 0.01, chi(2). Our retrospective case-controlled study suggests that gastric adenomas may be a new, significant risk factor for colonic polyps. A strong association would require that patients with gastric adenomas undergo surveillance colonoscopy to diagnose and remove colonic polyps. However, before we apply this finding to clinical practice, the apparent association should be confirmed by another, preferably prospective study.

Aged↗
PubMed1995

The endoscopic appearance of severe intestinal Mycobacterium avium complex infection as a coarsely granular mucosa due to massive infiltration and expansion of intestinal villi without mucosal exudation.

Although Mycobacterium avium complex (MAC) is the most common opportunistic pathogen at postmortem in patients with AIDS, many cases are not recognized premortem. A patient with advanced AIDS had diarrhea, fecal occult blood, and iron deficiency anemia. Esophagogastroduodenoscopy showed an extensive coarsely granular mucosa, resistant to endoscopic irrigation and brushing, in the descending duodenum. Histologic analysis of duodenal biopsies confirmed expansion of intestinal villi due to massive villar infiltration by acid-fast bacilli and no mucosal exudation. An absence of mucosal exudation is consistent with an attenuated local immunologic response in advanced AIDS. MAC was isolated from mycobacterial culture of duodenal biopsies. The currently reported endoscopic appearance of intestinal MAC can aid in diagnosis by alerting the endoscopist to send biopsies for mycobacterial stains and cultures when MAC infection is suggested by this endoscopic appearance. However, even in the absence of endoscopically evident lesions, gastrointestinal endoscopic biopsy is appropriate to exclude occult opportunistic pathogens in an AIDS patient with wasting or significant gastrointestinal complaints. The currently reported pathologic findings show that villar engorgement and hypertrophy is a sufficient explanation for the granular endoscopic appearance of intestinal MAC and that mucosal exudation is not required to produce this appearance.

AIDS-Related Opportunistic Infections↗
PubMed1995

A study of the safety and clinical efficacy of flexible sigmoidoscopy and colonoscopy after recent colonic surgery in 52 patients.

OBJECTIVE: Our objective was to evaluate the safety of lower endoscopy after colonic surgery, which has been unstudied and unknown. Endoscopy could promote suture breakdown at sites of colonic anastomoses, ostia, or repair by colonic abrasion or stretch from endoscopic intubation, torque, and insufflation. METHODS: Risks versus benefits of lower endoscopy performed within 3 wk of colonic surgery were retrospectively analyzed at five medical centers in 36 patients undergoing sigmoidoscopy and 72 age-and-sex-matched controls, and in 16 patients undergoing colonoscopy and 32 age-and-sex-matched controls. RESULTS: Sigmoidoscopy indications included rectal bleeding in 14, distal colonic obstruction in 12, and other in 10. Sigmoidoscopy provided the diagnosis in 18 (54%) of 33 cases (excluding three therapeutic sigmoidoscopies, control rate = 30%, p < 0.01, X2, including colon cancer in six and benign stricture in five. Sigmoidoscopy led to colonic surgery in nine and medical therapy changes in four. Colonoscopy indications included colonic bleeding in seven, colonic obstruction in five, and other in four. Colonoscopy provided the diagnosis in nine (56%, control rate = 56%, NS, X2). Colonoscopy led to colonic surgery in three and chemotherapy in one. Two endoscopic complications, unrelated to suture breakdown, occurred: An acutely ill patient developed hypotension during sigmoidoscopy which resolved with intravenous fluid resuscitation. A contained sigmoid diverticular perforation became a free perforation (requiring laparotomy) after colonoscopy. Both control groups had no endoscopic complications (NS, Fisher's exact test). CONCLUSION: In this study, the benefits outweighed the risks of postoperative sigmoidoscopy and colonoscopy. Clinicians should use discretion and perform colonoscopy or sigmoidoscopy after colonic surgery, particularly bowel anastomosis, only for clinically important indications. Endoscopy is contraindicated when colonic wound dehiscence or bowel perforation is suspected.

Colon↗
PubMed1995

A study of the safety and clinical efficacy of esophagogastroduodenoscopy after esophageal, gastric, or duodenal surgery in 60 patients.

OBJECTIVES: Our purpose was to evaluate the safety of esophagogastroduodenoscopy (EGD) after esophageal, gastric, or duodenal surgery, a previously unstudied subject. EGD could promote suture breakdown at sites of anastomoses, ostia, or repair by abrasion or stretch from endoscopic intubation, torque, or insufflation. METHODS: Risks versus benefits of EGD performed within 24 days of upper gastrointestinal surgery were analyzed at five medical centers in 60 study patients and were compared with 120 controls matched for age, sex, and EGD indication. RESULTS: Of 13,170 hospitalized patients undergoing EGD, 60 patients (0.46%) had EGD within 24 days of upper gastrointestinal surgery. EGD indications in study patients included gross upper gastrointestinal bleeding in 24, nausea and vomiting in 23, bright red blood per rectum in four, dysphagia in three, abdominal pain in three, and "other" in three. EGD was performed on average 14.7 +/- 7.2 (SD) days after surgery. EGD provided the diagnosis in 45 (75%) study patients (control rate = 77%, not significantly different, chi 2). In particular, postoperative EGD provided the diagnosis in 20 (83%) of 24 patients with upper gastrointestinal bleeding (control rate = 92%, not significantly different, Fisher's exact test). Thirteen study patients (22%) had upper gastrointestinal lesions directly related to surgery including: anastomotic ulcers in six, anastomotic erosions in six, and an excessively tight Nissen fundoplication in one. One additional patient at EGD had extrinsic duodenal compression attributed to postoperative adhesions. EGD led to surgery in nine and to successful endoscopic therapy in six. No study patient experienced an endoscopic complication. The control group had one endoscopic complication (not significantly different rates, Fisher's exact test). CONCLUSION: In this study, the benefits outweighed the risks of postoperative EGD when performed more than 7 days after surgery: the diagnostic yield was high and the complication rate was low. Indeed, the yield and risks were similar to that of other EGDs. Postoperative EGD identified a surgical complication in about 20% of cases. Clinicians should use discretion and perform postoperative EGD for clinically important indications. EGD is contraindicated when wound dehiscence or bowel perforation is suspected.

Case-Control Studies↗
PubMed1995

A study of the syndrome of simultaneous acute upper gastrointestinal bleeding and myocardial infarction in 36 patients.

OBJECTIVES: To analyze how acute upper gastrointestinal bleeding (GIB) with simultaneous myocardial infarction (MI) presents differently than either disease alone. METHODS: A multicenter, case-controlled study of 36 study patients with simultaneous upper GIB and MI was conducted. GIB-post-MI controls were 28 patients developing upper GIB more than 24 h after MI. MI controls were 36 patients with MI without GIB. GIB controls were 36 patients with upper GIB without MI. RESULTS: Study patients had more severe bleeding than GIB controls as indicated by significantly more units transfused and lower mean arterial pressure (74.8 +/- 17.3 mm Hg vs 88.7 +/- 14.9 mm Hg, p < 0.001, Student's t test). Massive bleeding may contribute to myocardial hypoperfusion and infarction. Study patients were significantly more likely than patients in any control group to present with syncope, dizziness, or confusion (e.g., study group, 56%, GIB-post-MI controls, 21%, odds ratio = 4.58, p < 0.01, chi 2). Neurological symptoms in study patients were usually attributable to hypovolemia, but in GIB-post-MI controls, all cases were attributable to arrhythmia or hypoxia and not hypovolemia (13 vs 0, p < 0.0002, Fisher's exact test). Syncope rarely led to neurological sequelae. Study patients tended to experience chest pain less frequently than GIB-post-MI or MI controls. Study patients had significantly greater mortality than either GIB controls (33 vs 8%, odds ratio = 5.5, p < 0.01, Fisher's exact test) or MI controls. CONCLUSION: Gastrointestinal findings generally predominate in patients with simultaneous upper GIB and MI. This syndrome is typically characterized by: massive bleeding; frequent syncope, dizziness, or confusion; rare neurological sequelae; moderately frequent absence of chest pain; and high mortality. MI may not be clinically suspected. Patients with upper GIB who deny chest pain but have warning signs of hypoperfusion such as syncope, confusion, dizziness, or hypotension should have MI excluded in an intensive care unit.

Aged↗
PubMed1995

Colonic tubulovillous adenoma associated with gastric heterotopia.

Gastric heterotopia in the colon proximal to the rectum is rare. The clinical spectrum of gastric heterotopia is extended by reporting a case that occurred in an elderly patient, associated with a colonic tubulovillous adenoma and treated by polypectomy without recurrence one year later.

Adenoma, Villous↗
PubMed1995

Endoscopic, radiographic, and manometric findings in dysphagia associated with sarcoid due to extrinsic esophageal compression from subcarinal lymphadenopathy.

Esophageal dysphagia associated with sarcoid has been attributed to dysmotility from neuropathy, dysmotility from myopathy, mechanical obstruction from esophageal mural involvement, and mechanical obstruction from extrinsic compression by subcarinal lymphadenopathy. The relative importance of these etiologies has not been evaluated because of variable and nonstandardized analysis. In particular, manometry has not been performed to exclude esophageal dysmotility in dysphagia attributed solely to extrinsic compression. A 42-yr-old male with chronic sarcoid for 20 yr presented with mild dysphagia to solids. An upper gastrointestinal series revealed smooth narrowing of the esophageal lumen and transient hang-up of the barium column and a 1.3-cm diameter radiopaque pill at the level of the carina. Chest computerized tomography revealed esophageal narrowing at the level of the carina and splaying of the two mainstem bronchi from compression by subcarinal lymphadenopathy. Esophagogastroduodenoscopy revealed elliptical esophageal narrowing due to multiple, smooth, and nodular deformities at 29-32 cm from the incisors. Pathological examination of deep biopsies of the nodules revealed normal mucosa and submucosa without granulomas. Esophageal manometry revealed a highly localized high pressure zone of 39.8 +/- 6.1 mm Hg at 29-31 cm from the incisors (lab normal about -5 mm Hg). Esophageal muscle contractions were peristaltic and of normal amplitude above, within, and below this high pressure zone. This case report demonstrates that extrinsic compression from subcarinal lymphadenopathy is a sufficient mechanism for dysphagia with sarcoid, but it does not exclude a role for other mechanisms, such as nerve injury, in some cases.

Adult↗
PubMed1994

Safety and clinical efficacy of flexible sigmoidoscopy and colonoscopy for gastrointestinal bleeding after myocardial infarction. A six-year study of 18 consecutive lower endoscopies at two university teaching hospitals.

The risks versus benefits of flexible sigmoidoscopy and colonoscopy performed within three weeks of myocardial infarction were studied in nine consecutive patients who underwent sigmoidoscopy and in nine consecutive patients who underwent colonoscopy at two university hospitals. Indications for sigmoidoscopy were red blood per rectum in seven and occult blood in the stools in two. Sigmoidoscopy provided the diagnosis in three, including colon cancer in two and bleeding internal hemorrhoids in one, and provided helpful information in three. Sigmoidoscopy led to colon cancer surgery in two patients, and polypectomy of a 1-cm adenoma in one. Of two highly unstable patients before sigmoidoscopy, one developed second-degree heart block and frequent premature ventricular contractions 3 hr after sigmoidoscopy. No sigmoidoscopic complications occurred in the seven relatively clinically stable patients. Indications for colonoscopy included red blood per rectum in five, occult blood in the stools in three, and melena in one. Colonoscopy provided the diagnosis in five, including one each with colon cancer, internal hemorrhoids, large adenoma, ischemic colitis, and angiodysplasia. Colonoscopy resulted in colon cancer surgery in one patient and endoscopic polypectomies in three patients. Of two moderately unstable patients before colonoscopy, one developed asymptomatic bradycardia during colonoscopy. No colonoscopic complications occurred in the seven clinically stable patients. This study suggests that recent myocardial infarction is not an absolute contraindication to sigmoidoscopy or colonoscopy, that sigmoidoscopy is beneficial in medically stable patients with significant gastrointestinal bleeding, and that colonoscopy may be beneficial in selected, highly stable patients with significant gastrointestinal bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1994

Gastrointestinal hemorrhage and intestinal ischemia associated with anticardiolipin antibodies.

Two patients developed unusual causes of severe gastrointestinal hemorrhage associated with anticardiolipin antibodies. One patient bled from small bowel ischemia and mesenteric thrombosis. Another patient bled massively from an ulcer of the descending duodenum which was refractory to standard antiulcer therapy. Ischemia may have contributed to the atypical ulcer presentation in this second patient, which included atypical ulcer location, ulcer refractoriness to standard peptic ulcer therapy, and severe recurrent hemorrhage. In five previously reported cases intestinal infarction associated with anticardiolipin antibodies presented, as it usually presents in patients without anticardiolipin antibodies, as an acute abdomen without acute gastrointestinal bleeding. The current study demonstrates that intestinal ischemia due to thrombosis is in the differential diagnosis of gastrointestinal bleeding in the anticardiolipin antibody syndrome.

Adult↗