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[A new system for noninvasive sampling of the upper gastrointestinal tract].
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Nonendoscopic transnasal placement of a wireless capsule for esophageal pH monitoring: feasibility, safety, and efficacy of a manometry-guided procedure.
BACKGROUND AND STUDY AIMS: The aim of the study was to evaluate the safety, feasibility, and efficacy of transnasal placement of the Medtronic Bravo capsule for wireless esophageal pH monitoring. PATIENTS AND METHODS: Forty patients with symptomatic gastroesophageal reflux disease were prospectively evaluated. All patients underwent upper gastrointestinal endoscopy and esophageal manometry. The Bravo capsule was then introduced transnasally and released 5 cm above the upper margin of the lower esophageal sphincter. Serial radiographs were performed weekly until capsule release. RESULTS: Of the 40 patients who were evaluated, 38 (95 %) were eligible to undergo the procedure. Transnasal placement proved impossible in one patient (2.5 %). Overall, a total of 39 procedures were performed in 38 patients (the procedure was repeated in one patient because of accidental intragastric fixation). Esophageal placement was successful in 36/39 procedures (92.3 %). The mean duration of the procedure was 10 minutes (range 5 - 16 minutes). Adverse events were noted in five of the 39 procedures (12.8 %), mild epistaxis in two patients (5.1 %) and pharyngeal irritation in three patients (7.7 %). After the procedure, a slight "foreign body" sensation was reported by 20 of the 36 patients (55.5 %) who had undergone successful esophageal placement; two patients (5.5 %) experienced severe retrosternal pain necessitating endoscopic removal of the capsule. At the end of the study, 34 of the 38 patients (89.5 %) stated that they would be willing to undergo the test again if necessary. CONCLUSIONS: Transnasal placement of the Bravo pH capsule is safe, well tolerated, does not require sedation, and avoids endoscopy and its complications.
Rotator interval capsule closure: an arthroscopic technique.
The importance of the rotator interval in glenohumeral instability has become increasingly apparent as anatomic studies have illustrated a significant increase in inferior and posterior translations after sectioning of the coracohumeral and superior glenohumeral ligaments. Limited reports of this lesion exist in the literature, and all such lesions have been treated with open procedures, with good clinical results. This report describes an arthroscopic technique for imbrication of the rotator interval in treating symptomatic defects and laxity in the anterosuperior shoulder capsule.
Endoscopy and biopsy of the colon.
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Posterior peripheral sutures in meniscal allograft replacement.
In our experience, meniscal allograft transplantation does have a role after a total or a significant partial meniscectomy in young to middle-aged symptomatic patients. While the quality of the meniscal tissue is crucial to the success of the operation, it is equally important to duplicate the mechanical function of the original semilunar cartilage and assure a secure peripheral attachment of the meniscal implant. The technique for peripheral meniscal suture placement described in this article permits an easier and more secure attachment of the posterior third of the implant to the joint capsule.
Histological comparison of suction capsule and endoscopic small intestinal mucosal biopsies in children.
Small intestinal biopsies are part of the routine evaluation of children with chronic diarrhea and malabsorption, and are commonly performed via suction capsule. Because this technique entails x-ray exposure, longer procedure time, and technical failures, most small intestinal biopsies in adults are currently obtained via endoscopy. Endoscopy is believed to yield morphologically inferior specimens, and, therefore, its use for obtaining small intestinal biopsies in children has remained limited. The histological adequacy of biopsy specimens obtained in 30 children by endoscopy and in 30 children by suction capsule was compared. Biopsies were assessed for quality of orientation, size (length and depth), presence of Brunner's glands and crush artifact, and for the ability to confirm or exclude a mucosal abnormality. Small intestinal biopsies obtained via endoscopy were shown to yield tissue specimens that are histologically comparable to those obtained by suction capsule, and that are equally suitable for interpretation.
An ambulant porcine model of acid reflux used to evaluate endoscopic gastroplasty.
BACKGROUND: There is a lack of suitable models for testing of therapeutic procedures for gastro-oesophageal reflux disease. Endoscopic sewing methods might allow the development of a new less invasive surgical approach to treatment of gastrointestinal disorders. AIMS: To develop an animal model of gastro-oesophageal reflux for testing the efficacy of a new antireflux procedure, endoscopic gastroplasty, performed at flexible endoscopy without laparotomy or laparoscopy. METHODS: At endoscopy a pH sensitive radiotelemetry capsule was sewn to the oesophageal wall, 5 cm above the lower oesophageal sphincter, in six large white pigs. Ambulant pH recordings (48-96 hours; total 447 hours) were obtained. The median distal oesophageal pH was 6.8 (range 6.4-7.3); pH was less than 4 for 9.3% of the time. After one week, endoscopic gastroplasty was performed by placing sutures below the gastro-oesophageal junction, forming a neo-oesophagus of 1-2 cm in length. Postoperative manometry and pH recordings (24-96 hours; total 344 hours) were carried out. RESULTS: Following gastroplasty, the median sphincter pressure increased significantly from 3 to 6 mm Hg and in length from 3 to 3.75 cm. The median time pH was less than 4 decreased significantly from 9.3% to 0.2%. CONCLUSIONS: These are the first long term measurements of oesophageal pH in ambulant pigs. The finding of spontaneous reflux suggested a model for studying treatments of reflux. Endoscopic gastroplasty increased sphincter pressure and length and decreased acid reflux.
Continuous curvilinear capsulorhexis with use of an endoscope.
We describe a technique for creating a continuous curvilinear capsulorhexis (CCC) using an endoscope. Three 2.0 mm limbal incisions 120 degrees apart were made in 4 cadaver eyes. The anterior capsule was stained with trypan blue 0.1% (Vision Blue). Under endoscopic visualization, a CCC was attempted in each of the 4 globes. It was completed in 1 of them. Endoscopy provides a safe and effective tool to visualize the anterior chamber and perform a CCC when there is a poor view through the cornea.
Comparison of suction capsule and endoscopic biopsy of small bowel mucosa.
Small bowel mucosal biopsy specimens were studied in 52 consecutive patients. Twenty-six patients underwent biopsy by a suction capsule and 16 patients by endoscopy using an 8-mm forceps. Additionally, 10 patients were asked to undergo biopsy by both techniques in the same morning. Material was obtained in 81% of attempts by suction and 100% by endoscopy. Tissue obtained was excellent in 58%, good in 28%, and poor in 14% of suction biopsy specimens. Corresponding grades for endoscopy were 65%, 31%, and 4%. The frequency of abnormal findings was not different by either technique. In the 10 patients who had both procedures, mean time to completion was 43 min by suction and 12 min by endoscopy. Intravenous premedication was used in endoscopy, and patient comfort was judged as excellent in 60% with endoscopy, whereas 60% judged suction biopsy as very uncomfortable. The mean fluoroscopy time of 3.9 min necessary for suction biopsy was eliminated with endoscopy. Biopsy with an 8-mm forceps through the endoscope is the preferred way to obtain tissue from the proximal small bowel.
Protein-losing enteropathy in an unusual form of sarcoidosis.
We describe a case of sarcoidosis associated with great gastrointestinal loss of proteins. It was hypothesized that the loss was caused by involvement of sarcoidosis in the gastrointestinal tract. The patient was a 39-year-old woman with sarcoidosis diagnosed at age 32 years. The protein-losing enteropathy was identified by the use of [51Cr]-albumin. An extensive investigation was performed, with biopsy specimens taken from all parts of the gastrointestinal tract, using upper gastrointestinal endoscopy, colonoscopy and the Crosby capsule technique. We could find no support for our hypothesis that the leakage of proteins was caused by involvement of sarcoidosis in the gastrointestinal tract. Thus, mechanisms other than direct inflammatory involvement of the gastrointestinal mucosa probably caused protein-losing enteropathy in this patient.
The prevalence of celiac disease among family members of celiac disease patients.
INTRODUCTION: Celiac disease (CD) is more common in certain risk groups. Family members of known celiac patients represent the most important group. Serological screening enables us to detect patients before they develop serious complications. HLA typing has also proven to be a valuable diagnostic tool, especially in excluding the disease. METHODS: To assess the prevalence of CD among family members, we screened 106 first-degree relatives (73 parents, 33 siblings; mean age 27.9 years) of 45 celiac patients in NE Slovenia. We analysed antigliadin (AGA) and antiendomysium (EMA) antibodies. Levels of IgG and IgAAGA were determined using the ELISA method, and EMA using indirect immunofluorescence. Serologically positive patients were recalled for intestinal biopsy and were HLA typed. Intestinal biopsy was performed by peroral aspiration capsule or during upper GI endoscopy. Biopsy specimens were examined histologically. RESULTS: Six family members (5.67%) were both AGA IgG and EMA positive, and one (0.94%) was only EMA positive. All were either HLA DQ2 or DQ8 positive. Nine family members (8.49%) were only AGA IgG positive, two of them lacked the HLA DQ susceptibility alleles. Intestinal biopsy was performed in six family members, and the diagnosis of CD confirmed in five. All were both AGA IgG and EMA positive. They were either symptom-free or had only mild gastrointestinal symptoms, and carried the known HLA DQ risk alleles. The minimum prevalence of CD among family members in NE Slovenia can therefore be estimated at 4.72%. DISCUSSION: The prevalence of CD among first-degree relatives is much higher than the prevalence of the disease in the general population. Most of these patients have an atypical form of the disease and would therefore be overlooked without an active search. Serological testing is recommended for all first-degree relatives of CD patients; they should also undergo HLA typing to detect those whose HLA phenotype is consistent with CD. This approach can also help in excluding individuals who do not need further diagnostic procedures for CD.
Gastrointestinal-tract models and techniques for use in safety pharmacology.
The gastrointestinal tract (GI tract), which extracts nutrients, electrolytes, minerals, and water, is prone to injury as a result of oral drug administration. Clinical assessment of the GI tract is often limited to measurements of transit time and observations of vomiting or diarrhoea, despite the existence of methods and techniques capable of assessing specific changes in GI function at the membrane, cell, and whole animal levels. Membrane studies, record the uptake of solutes, and electrolyte transport, assessing the affects of compounds on transepithelial GI transport and flux. Such methods lend themselves to permeability, immunohistochemistry, morphology, and molecular biology techniques. Isolated cells from the GI tract or cultured cell lines provide knowledge of regulation and function at a cellular level, whilst motility patterns, taken in vivo or from biopsies, provide information at a more integrated level. In anesthetised animals, ligated segments of the intestine can be infused with test compounds, providing information about absorptive and secretory processes important for the treatment of diarrhoea. Computer simulations and modelling are used to predict the disposition of a chemical and its metabolite and can, to some extent, replace animal testing, thereby reducing development costs. Indeed, software programs can be used to simulate the dissolution, absorption, distribution, metabolism, and excretion (ADME) properties of potential drugs in the human GI tract. Finally, advances in the field of imaging, combined with endoscopy, have resulted in a wireless capsule, allowing the inspection of the GI tract anatomy and pathology without surgical intervention. It is concluded that the field of safety pharmacology could rapidly, cheaply, and routinely incorporate membrane, isolated tissue, and endoscopy techniques for GI tract testing of drugs.
Usefulness of endoscopic small intestinal biopsies in children with coeliac disease.
Small intestinal biopsy is the most important diagnostic method in the routine evaluation of children with chronic diarrhoea and malabsorption. At present morphological alterations are considered essential in the diagnosis of coeliac disease (CD) and the presence of a normal small bowel biopsy specimen, observed in patients eating a diet containing gluten, rules out the diagnosis of CD. The small intestinal biopsy can be carried out either by blind suction capsule or by endoscopic forceps. In everyday clinical practice endoscopic duodenal biopsies, if taken and handled suitably, are accepted as equivalent to capsule biopsies from the proximal jejunum. In the study we reported some patients in whom has been possible to demonstrate the presence of total villous atrophy in one biopsy, while other duodenal samples taken in different duodenal portions were normal or showed mild lymphocytes and plasmacells infiltrations of the lamina propria. In patients with this type of biopsy pathology, wherein flat mucosa has been found even close to normal mucosa, the possible explanation is mucosal patchiness. The occurrence of patchly distributed intestinal atrophy in children suffering of CD raises the question of the validity of using the peroral capsule, widely believed to be the best standard for the diagnosis of CD. In our opinion, small intestinal biopsies obtained via endoscopy are more reliable than the peroral capsule biopsies in order to identify patchy mucosal atrophy and could be very useful for a correct diagnosis in CD patients.
Upper gastrointestinal endoscopy in the pediatric patient.
During a 4 year period (January 1988 to December 1991), 237 pediatric patients (mean age +/- SD, 9.75 +/- 5.17 years) underwent 289 upper gastrointestinal endoscopies. Premedication was used in only 102 of the endoscopic examinations, mostly in children between 2 and 10 years of age. Patients who were examined without sedation tolerated the procedure well. Abdominal pain was the most frequent indication, accounting for 57.4% of all procedures. Gastritis, esophagitis, duodenitis and duodenal ulcer were the most common endoscopic findings. Seventy-five endoscopies were performed to obtain small bowel biopsies. We found this procedure to be easy and safe and preferable to capsule biopsies. In our experience, upper gastrointestinal endoscopy with or without sedation is a safe and effective diagnostic procedure in the pediatric age group.
Comparison of fiberendoscopy and Watson capsule for small intestinal biopsy in infants and children.
We analyzed the results of 607 small bowel biopsies performed over a seven-year period: 284 biopsies were obtained using a fiberendoscope and 323 biopsies using a Watson capsule. Three to six specimens were removed during endoscopy. The biopsy fragments obtained with the fiberendoscope were deeper than those obtained with the Watson capsule (p less than 0.0001) and were more often located in the duodenum (p less than 0.0001). The failure rate of the fiberendoscope biopsies (1%) was lower than for the Watson capsule biopsies (9%) (p less than 0.0001). Multiple biopsies increased the diagnostic value of fiberendoscopy which was 95% versus 85% for Watson capsule. The mean duration of the endoscopic procedure recorded in 30 children was 6.5 min for four to six samples, i.e. 1.5 min per biopsy specimen. Fiberendoscopy appears to be an efficient and safe method for performing small bowel biopsies in infants and children.
Severe corrosive gastritis related to Drano: an unusual case.
A case of lye ingestion by a suicidal patient in the form of Drano in capsules is reported. Although lye ingestion usually causes lesions in the oropharynx and severe esophagitis, in our patient it produced severe gastritis with minimal esophageal findings because of the protective capsules which dissolved primarily in the stomach. Endoscopy should be the first method of evaluating patients with ingestion of corrosives, but an upper gastrointestinal (UGI) series can accurately demonstrate mucosal injury and extent of involvement. UGI can be used as an adjunct in patients incompletely examined by endoscopy and can play an important role in the follow-up examination of these patients.
On-demand PPI requirements in patients with endoscopy-negative GERD.
GOALS: To evaluate the need for on-demand treatment with proton pump inhibitor in patients with endoscopy-negative GERD. BACKGROUND: Studies indicate that on-demand therapy is suitable for patients without mucosal disease, but the need for PPI in a monotherapy situation is not known. STUDY: Forty-one patients with heartburn and/or acid reflux of more than 3 months duration participated in the study. All were endoscopy-negative and had responded positive to a test with lansoprazole 60 mg x 1 for 7 days. Twenty-four hour pH monitoring was attempted in all, but failed in 4. Twenty-eight had pH <4 more than 4% of the time, 9 had less. During a 3-month period, the patients were allowed to take 1 capsule 30 mg lansoprazole on-demand, maximum 2 capsules a day. The remaining capsules were counted monthly. RESULTS: In the 3-month period, the median mean daily consumption was 1.06 capsule (95% CI: 0072-1.09). No significant difference was found between those with normal or abnormal 24-hour pH-metry. Sixty-three percent used 6 or more capsules a week. CONCLUSION: Patients with longstanding negative-endoscopy reflux disease, whether abnormal or normal 24-hour pH-metry, have symptoms that demand effective therapy. Using PPI on-demand as monotherapy, most patients will need 1 capsule per day.