[Anal blood loss: remember the thermometer!].
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Adult↗
Biomedical subjects
M van Blankenstein
Publications and source records attributed to M van Blankenstein.
Spontaneous bacterial peritonitis complicating malignancy-related ascites.
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Ascites↗
Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and management.
UNLABELLED: Benign stricture formation at the cervical anastomosis after transhiatal esophagectomy with gastric tube interposition is an important source of morbidity. In a large group of patients (n = 269) who had undergone transhiatal esophagectomy with gastric tube interposition, we examined surgical and nonsurgical risk factors for the development of benign strictures at the cervical anastomosis. In addition, we evaluated the results of endoscopic bougie dilation in patients in whom an anastomotic stricture developed. RESULTS: During follow-up, 114 patients (42%) had a benign anastomotic stricture. Only a history of cardiac disease (P = 0.03), postoperative leakage at the anastomosis (p = 0.002), and a stapled rather than a hand-sewn anastomosis (p = 0.04) were found to be independent risk factors for the development of a stricture. In 27 of 60 patients with anastomotic leakage, contrast swallow examination demonstrated only a leak at the anastomosis. Endoscopic bougie dilation of anastomotic strictures was successful in 78% of patients after a median of three dilation sessions (range 1 to 28). In 3% of patients dilations were still being performed, and 19% of patients had died before normal swallowing had been achieved. In two of 519 (0.4%) dilation sessions a major complication occurred. CONCLUSIONS: (1) Patients with preoperative cardiac disease are at an increased risk for anastomotic stricture. (2) Even in patients having no symptoms, a contrast swallow can detect anastomotic leakage that results in an increased risk for the development of anastomotic strictures. (3) The benefit of the stapler device for anastomosis remains to be determined. (4) Endoscopic bougie dilation with the patient mildly sedated is a safe and effective method for the treatment of anastomotic strictures.
Adult↗
Oesophageal cancer is an uncommon cause of death in patients with Barrett's oesophagus.
BACKGROUND: Barrett's oesophagus carries a 30-fold to 40-fold increased risk of oesophageal cancer. It is unknown whether endoscopic surveillance programmes reduce mortality from oesophageal cancer. METHODS: A cohort study was undertaken of all 166 patients in whom the diagnosis Barrett's oesophagus had been established between 1973 and 1986. RESULTS: One hundred and fifty five of 166 patients could be traced (93%). During a mean follow up of 9.3 years (amounting to 1440 patient years) eight patients had developed oesophageal cancer at random intervals (one case in 180 patient years). All but one of the tumours were diagnosed at endoscopy for symptoms, three in the stage of carcinoma in situ. Risk factors for the development of oesophageal cancer were extensive Barrett's oesophagus exceeding 10 cm (p = 0.02) and Barrett's ulcer at the time of intake (p = 0.009). Seventy six patients were alive; three had undergone surgery for oesophageal cancer and were without recurrence respectively, 12.8 years, 12.1 years, and 7 months postoperatively. Seventy nine patients had died; five of them had developed oesophageal cancer, but in only two cases this had been the cause of death (2.5%). CONCLUSIONS: Oesophageal cancer is an uncommon cause of death in patients with Barrett's oesophagus. The patients of this cohort would not have benefited from an endoscopic surveillance programme.
Aged↗
Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD).
BACKGROUND: It has been suggested that the incidence of inflammatory bowel disease (IBD), which includes ulcerative colitis (UC) and Crohn's disease (CD), is three or more times higher in northern than in southern Europe. The aim of this EC funded study was to investigate this apparent variation by ascertaining the incidence of IBD across Europe. METHODS: For the period 1 October 1991 to 30 September 1993 all new patients diagnosed with IBD were prospectively identified in 20 European centres according to a standard protocol for case ascertainment and definition. FINDINGS: Altogether 2201 patients aged 15 years or more were identified, of whom 1379 were diagnosed as UC (including proctitis), 706 as CD, and 116 as indeterminate. The overall incidence per 100,000 at ages 15-64 years (standardised for age and sex) of UC was 10.4 (95% confidence interval (95% CI) 7.6 to 13.1) and that of CD was 5.6 (95% CI 2.8 to 8.3). Rates of UC in northern centres were 40% higher than those in the south (rate ratio (RR) = 1.4 (95% CI 1.2 to 1.5)) and for CD they were 80% higher (RR = 1.8 (95% CI 1.5 to 2.1)). For UC the highest reported incidence was in Iceland (24.5, 95% CI 17.4 to 31.5) and for CD, Maastricht (The Netherlands; 9.2, 95% CI 6.5 to 11.8) and Amiens (north west France; 9.2, 95% CI 6.3 to 12.2). The lowest incidence of UC was in Almada (southern Portugal) (1.6, 95% CI 0.0 to 3.2) and of CD in Ioannina (north west Greece) (0.9, 95% CI 0.0 to 2.2). An unexpected finding was a difference in the age specific incidence of UC in men and women with the incidence in women but not men declining with age. INTERPRETATION: The higher overall incidence rates in northern centres did not seem to be explained by differences in tobacco consumption or education. Nevertheless, the magnitude of the observed excess for both conditions is less than expected on the basis of previous studies. This may reflect recent increases in the incidence of IBD in southern Europe whereas those in the north may have stabilised.
Adolescent↗
Treatment of colitis in Behçet's disease with thalidomide.
A 40-year-old Turkish man on busulphan treatment for chronic myeloid leukaemia was hospitalized with steroid resistant (up to 100 mg prednisolone/24 h for over 4 weeks) colitis. On the basis of concomitant orogenital ulceration and unusual, deep punched out ulcers in the colon and smaller ulcers in the terminal ileum, Behçet's disease of the bowel, manifesting as ileocolitis, was diagnosed. Leukaemic infiltration, Crohn's colitis, neutropenic colitis and infectious colitis were excluded by histology and cultures. Treatment with colchicine 2 mg/day improved the orogenital ulcers but with only minor improvement of the colitis. Thalidomide treatment (400 mg/day), however, dramatically improved the colitis within 7 days: fever and diarrhoea disappearing. Colonoscopy after 4 weeks of treatment revealed previously giant ulcers practically healed.
Adult↗
Octreotide for protein-losing enteropathy with intestinal lymphangiectasia.
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Adrenal Cortex Hormones↗
Accumulation of genetic abnormalities during neoplastic progression in Barrett's esophagus.
Sex chromosome status, ploidy, and proliferation rate were evaluated in archival material of 73 Barrett's esophagus patients (48 males and 25 females). Diagnosis in esophageal mucosa samples ranged from intestinal metaplasia with no dysplasia to invasive esophageal adenocarcinoma; also, four lymph node metastases were studied. Chromosomal and ploidy aberrations were determined by in situ hybridization with repetitive DNA probes specific for chromosomes Y, X, and 1. Proliferation index (Ki-67 protein expression) was assessed by immunohistochemistry. Proliferation rate was elevated in all stages of dysplasia and in the adenocarcinomas. Aneuploidy (hyperdiploidy) and loss of the Y chromosome correlated with the advancing stages toward neoplasia (P < 0.001) and reached high prevalences (70-100%) in high-grade dysplasia and adenocarcinoma. Abnormalities of the X chromosome were not seen. These data suggest that in Barrett's esophagus, genetic perturbations may be generated in relation to a high proliferation rate.
Adenocarcinoma↗
Accumulation of p53 protein in normal, dysplastic, and neoplastic Barrett's oesophagus.
Accumulation of p53 protein was determined by immunohistochemistry in archival material of biopsy specimens from 102 patients with Barrett's oesophagus with different grades of dysplasia, in 24 oesophageal adenocarcinomas associated with Barrett's oesophagus, and in 23 cases of metaplastic epithelium adjacent to these carcinomas. Immunostaining for the p53 protein was found in 23/102 (23 per cent) cases of the Barrett's oesophagus biopsies and in 12/23 (52 per cent) cases of Barrett's oesophagus adjacent to adenocarcinoma. Significant correlations were found between the grade of dysplasia and p53 immunoreactivity in both Barrett's biopsies without adenocarcinoma (P < 0.001) and Barrett's oesophagus adjacent to adenocarcinoma (P < 0.05). In the adenocarcinomas, intense nuclear immunohistochemical staining for p53 was diffusely or focally present in 20/24 (83 per cent) of the specimens. In Barrett's oesophagus, p53 is a progression marker with high expression in high-grade dysplasia (89 per cent) and adenocarcinoma (83 per cent).
Adenocarcinoma↗
Early detection and treatment of oesophageal and gastric cancer. The Rotterdam Oesophageal Tumour Study Group.
Early oesophageal and gastric cancer are unique forms of oesophageal and gastric carcinoma with an excellent prognosis. Remarkable changes have taken place in the epidemiology of upper gastrointestinal malignancies. In particular, the incidence of adenocarcinoma of the distal oesophagus and the gastric cardia has risen over the past two decades. In the United States and Europe, early detection is dependent on a low threshold for upper gastrointestinal endoscopy with biopsy, because specific symptoms and physical findings are rarely present in patients with early oesophageal and gastric cancer. In addition to histology, the detection of possible markers of malignancy, such as aneuploidy (detected by flow cytometry) and the presence of oncogenes and tumour-suppressor genes, in biopsy material may be of value in the diagnosis of early cancers. For patients with early oesophageal or gastric cancer, surgery offers the best hope of cure. If patients are at high risk for surgery, an endoscopic resection may be an alternative option. This review discusses the definitions, the changes in epidemiology, the current options for diagnosis and treatment, and the value of screening programs for patients with early oesophageal or gastric cancer.
Barrett Esophagus↗
Needle-knife sphincterotomy guided by a biliary endoprosthesis in Billroth II gastrectomy patients.
BACKGROUND AND STUDY AIMS: All available techniques for performing endoscopic sphincterotomy in Billroth II gastrectomy patients have their limitations, and no standard technique has emerged. A new technique, needle-knife sphincterotomy guided by a thin (7 Fr) biliary endoprosthesis, is described here that overcomes some of the limitations of other techniques. PATIENTS AND METHODS: The technique was attempted in 19 nonselected patients during a three-year period. The results were retrospectively assessed. The outcome variables were the achievement of an adequate sphincterotomy and complications. RESULTS: An adequate sphincterotomy could be performed without much technical difficulty in 18 of the 19 patients. There was one complication, a retroperitoneal leakage, that settled with conservative treatment. CONCLUSIONS: In patients with Billroth II anastomoses, endoprosthesis-guided sphincterotomy is a new and relatively easy procedure, which is especially attractive once selective bile duct cannulation has been achieved. This technique allows the performance of sphincterotomy as a well-controlled procedure, and may, therefore, be safer than nonguided techniques. In contrast to previously reported guided techniques using nasobiliary cannulas, the endoprosthesis technique does not necessitate withdrawing and reinserting the endoscope.
Aged↗
Endoscopic sphincterotomy and biliary drainage in patients with cholangitis due to common bile duct stones.
OBJECTIVES: In a prospective study, we analyzed 95 consecutive patients undergoing endoscopic papillotomy (EP) for cholangitis due to common bile duct (CBD) stones; our purpose was to evaluate the risk factors influencing the complication rate due to cholangitis, with special attention to the clinical history. METHODS: Patients with previous gastric surgery or EP were excluded. Complications subsequent to sphincterotomy were recorded over a 3-month period. RESULTS: In patients with persistent cholangitis before EP, the risk for complications due to cholangitis increased with increasing delay between the onset of cholangitis and biliary drainage. In patients with a good response to antibiotics before EP, the delay in biliary drainage did not influence the risk of complications. After complete CBD stone removal, the morbidity (42% vs. 4%, p = 0.001) and the mortality (8% vs. 0%, NS) due to cholangitis were much higher in 12 patients with progressive cholangitis for > 3 days before biliary drainage, compared with 73 cases who had experienced a good response to antibiotics before EP and/or early drainage (< 3 days) after the onset of cholangitis. Two patients with advanced cholangitis and septic shock at the time of EP died < 12 h after completed sphincterotomy with CBD stone removal. Three patients with retained CBD stones and failed biliary drainage after EP experienced disastrous morbidity (100% vs. 9%, p < 0.01) and mortality (67% vs. 1%, p < 0.01) due to cholangitis, compared with 85 patients without retained CBD stone(s). CONCLUSIONS: We recommend emergency biliary drainage in all patients presenting with calculous cholangitis who are severely ill with continuous fever for several days. Emergency nasobiliary drainage without EP or after a limited EP may be a safer treatment in patients with (impending) septic shock. We believe that a more conservative approach is justified in patients presenting with symptoms of mild cholangitis, restricting emergency biliary drainage for those who do not respond rapidly (< 24 h) to antibiotics. Further emergency surgical or percutaneous biliary drainage should be performed immediately on patients in whom CBD stones are retained, after EP and drainage fails, especially if a stone is left impacted distally.
Adult↗
Prognostic value of p53 in Barrett's oesophagus.
During the last 30 years, the incidence of oesophageal adenocarcinoma has increased rapidly. Patients with Barrett's oesophagus have an increased risk of developing oesophageal adenocarcinoma and should be kept under surveillance. However, only a subset of Barrett's oesophagus patients will eventually develop malignancy and surveillance programs using endoscopy and histopathology cannot efficiently identify this subgroup. The study of additional prognostic factors is therefore of major importance and the p53 tumour suppressor gene has attracted much attention in this respect. Several investigators have found that p53 alteration is a frequent event in oesophageal adenocarcinomas and is associated with malignant transformation of Barrett's oesophagus. p53 appears to be a promising prognostic marker in Barrett's oesophagus and, as research progresses, possible clinical applications are emerging.
Adenocarcinoma↗
The presence of peptidoglycan-polysaccharide complexes in the bowel wall and the cellular responses to these complexes in Crohn's disease.
Interestingly, using a monoclonal antibody, peptidoglycan-polysaccharide complexes (PPC) were detected intracellularly in the mucosa and submucosa of the bowel wall of Crohn's disease (CD) patients. PPC are the main constituents of the gram-positive bacterial cell wall. These PPC were however detected in the normal bowel wall also. Therefore, in this study the hypothesis that an enhanced immune responsiveness to bacterial antigens plays a pivotal role in the induction or the chronicity of CD was tested. As antigens, the peptidoglycan structures of intestinal bacteria (Eubacterium aerofaciens or fecal PPC) or of Streptococcus pyogenes, the 65-kDa heat shock protein and muramyl dipeptide (MDP), the smallest bioactive subunit of peptidoglycan, were used. The proliferative responses of peripheral blood (PB) mononuclear cells (MNC) of healthy subjects and patients in a remissive stage of CD or an active CD stage were examined. Of this last patient group the MNC responses of the mesenterial lymph nodes that drain the inflamed gut area were measured also. The responses of PB-MNC of the healthy subjects and the patients in a remissive CD stage were not different. Compared to the responses in remissive CD, the PB-MNC responses in active CD to the eubacterial cell wall and streptococcal cell wall antigen were significantly higher. At the inflammation site in active CD, the lymph nodes, the responses to most of the bacterial antigens were significantly higher than in the PB. In summary, the results show the presence of bacterial peptidoglycan in the bowel wall and the immune responsiveness, especially at the inflammation site, to these antigens in active CD and therefore present suggestive evidence for the role of peptidoglycan in the etiology and/or pathogenesis of CD.
Adult↗
Endoscopic papillotomy for common bile duct stones: factors influencing the complication rate.
In a prospective study, the complications observed in 242 consecutive patients after endoscopic sphincterotomy for common bile duct stones were recorded over a period of up to three months. Patients with previous gastric surgery, papillotomy, or additional pancreato-biliary disease other than gallbladder stones were excluded. The overall complication rate was 14%, 74% of these complications being moderate or severe. The complication rate due to cholangitis was higher in (1) the group with retained stones following complete papillotomy and without biliary drainage, and (2) the group with failed precut papillotomy and drainage after cholangiography, both compared to patients with successful drainage (75% vs. 2.6%: p < 0.001 and 40% vs. 2.6%: p = 0.001 respectively). Both pancreatitis and retroperitoneal air leakage occurred in 1.7% of cases. They were more frequently observed in patients with a smaller diameter (< 10 mm) in the distal common bile duct (5.6% vs. 0%: p = 0.007 for pancreatitis, and 2.8% vs. 1.2%; n.s. for perforation) and especially following precut papillotomy (13.0% for pancreatitis and 8.7% for perforation), which had to be performed more often in these patients. Bleeding following sphincterotomy was relatively frequent when the papilla was located at the lower rim of or inside a diverticulum, compared to patients without a diverticulum (16.2% vs. 2.7%: p = 0.004 and 26.7% vs. 2.7%: p < 0.001 respectively). When the papilla was located inside diverticula, both the rate of perforation and bleeding increased following precut papillotomy, compared with standard papillotomy only (33% vs. 0%, n.s., and 33% vs. 22%, n.s.).(ABSTRACT TRUNCATED AT 250 WORDS)
Acute Disease↗
The contents of free-text endoscopy reports: an inventory and evaluation by peers.
Insight into the current status of endoscopy reports is needed for a discussion on the desirability and feasibility of (more) standardized endoscopy reporting. We collected, from ten endoscopists, 181 reports in two diagnostic and two indication categories. An inventory was made of the subjects dealt with in the reports, such as: indication, premedication, therapy plan, and descriptive aspects of ventricular ulcers and lower tract polyps. To assess endoscopists' opinions on their reports, 16 randomly selected reports were reviewed by the ten endoscopists, using the Delphi method. The reports varied enormously in content and detail; 19 of the 28 subjects were not explicitly described in more than 50% of the studied reports. Such variation in the contents of reports may decrease the quality of care. The large number of topics that endoscopists indicate to be missing in their reports (on average 14 topics per report) suggests that more detail should be given in endoscopy reports. The current method of reporting causes endoscopists to omit information that they consider important. Due to the low overall consensus among endoscopists on which specific topics to include (eight or more endoscopists agreed on 15% of topics) we conclude that general criteria for the contents of reports cannot yet be formulated. However, the fact that the endoscopists agreed with more than one-third of the remarks made by colleagues opens a perspective towards identifying criteria for the formalization of certain report categories.
Delphi Technique↗
Guidelines for the application of surgery and endoprostheses in the palliation of obstructive jaundice in advanced cancer of the pancreas.
OBJECTIVE: This study was set up to identify patient-related factors favoring the application of either surgery or endoprostheses in the palliation of obstructive jaundice in subsets of patients with cancer of the head of the pancreas or periampullary region. SUMMARY BACKGROUND DATA: In the palliation of obstructive jaundice, surgical biliodigestive anastomosis has traditionally been performed. Surgical biliary bypass is associated with high mortality (15% to 30%) and morbidity rates (20% to 60%) but little recurrent obstructive jaundice (0% to 15%). Biliary drainage with endoscopically placed endoprostheses has a lower complication rate, but recurrent obstructive jaundice is seen in up to 20% to 50% of patients. METHODS: Patients with advanced cancer of the head of the pancreas or periampullary region treated at the University Hospital Dijkzigt, Rotterdam, The Netherlands, between 1980 and 1990 were reviewed. In 148 patients, data were compared concerning the morbidity and hospital stay after the palliation of obstructive jaundice with endoscopic endoprostheses or surgical biliary bypasses. These patients were stratified for long (> 6 months) and short (< 6 months) survival times. RESULTS: In short-term survivors, the higher late morbidity rates after endoprostheses were offset by higher early morbidity rates and longer hospital stays after the surgical bypass. In long-term survivors, there was no difference in the hospital stay between the two groups, but the late morbidity rate was significantly higher in the endoprosthesis group. CONCLUSIONS: These data suggest that endoscopic endoprosthesis is the optimal palliation for patients surviving less than 6 months and surgical biliary bypass for those surviving more than 6 months. This policy necessitates the development of prognostic criteria, which were obtained by Cox proportional-hazards survival analysis. Advanced age, male sex, liver metastases, and large diameters of tumors were unfavorable prognostic factors. With these factors, the risk of short- or long-term survival can be predicted. It is hoped that the application of these data may allow a rational approach toward optimal palliative treatment of this form of malignant obstructive jaundice.
Aged↗