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Sedation for fibreoptic gastroscopy: a comparative study of midazolam and diazepam.

Midazolam, a water-soluble benzodiazepine, was compared with diazepam in fat emulsion (Diazemuls) as sedation for outpatient gastroscopy in a randomized double-blind fashion. Midazolam 0.05 mg kg-1 was found to be approximately equipotent to Diazemuls 0.15 mg kg-1. There were no differences concerning speed of recovery and all patients were considered ready for discharge after 2 h. Venous tolerance was good for both drugs. With the same degree of sedation, midazolam produced a higher frequency of amnesia (60% v. 7%; P less than 0.001) for the endoscopic procedure. Although the patients appeared to prefer midazolam to Diazemuls, this difference was significant only in patients who had not previously undergone gastroscopy (P less than 0.05). The high degree of amnesia with midazolam may be an advantage in sedation for unpleasant procedures like gastroscopy.

Adolescent↗

Sevoflurane-nitrous oxide or halothane-nitrous oxide for paediatric bronchoscopy and gastroscopy.

We have studied 120 infants and children, in three age groups (3-11 months, 1-5 yr and 6-15 yr), to compare anaesthesia with sevoflurane or halothane for bronchoscopy or gastroscopy, or both. Premedication or i.v. anaesthetic agents were not used. Patients were allocated randomly to receive either 7% sevoflurane or 3% halothane in 66% nitrous oxide in oxygen for induction of anaesthesia. The same inspired mixture was continued during bronchoscopy while the concentration of the inhalation agent was reduced by 50% during gastroscopy. Induction times were shorter for infants than for children and shorter for sevoflurane than for halothane. Cardiac arrhythmias were significantly more frequent during halothane than during sevoflurane anaesthesia. Physiological and psychomotor recovery were more rapid after sevoflurane than after halothane. At 24-h follow-up, children who received sevoflurane had significantly less nausea and vomiting. We conclude that sevoflurane was superior to halothane for paediatric bronchoscopy and gastroscopy.

Adolescent↗

Magnetic resonance imaging gastrography: evaluation of the dark lumen technique compared with conventional gastroscopy in patients with malignant gastric disease.

OBJECTIVES: We sought to demonstrate the feasibility of depicting gastric tumors using magnetic resonance imaging (MRI) while applying the dark lumen technique. The findings were correlated with conventional gastroscopy. In addition, we evaluated the screening for lymph nodes and liver metastases during the same session to identify potential tumor spread. MATERIALS AND METHODS: The study included 15 patients with known malignant gastric disease. Conventional gastrointestinal endoscopy was performed in all patients as gold standard. All patients were examined with computed tomography for tumor staging. MRI was performed using 1 L of tap water as oral contrast agent for all protocols. The MRI program included an axial T1-weighted (T1w; 2D-FLASH) sequence, an axial STIR and T2w (TSE) sequence, and 2 postcontrast T1w (3D coronal /2D axial FLASH) sequences using 0.2 mmol/kg gadolinium diethylenetriaminepenta-acetic acid as intravenously injected contrast agent. Qualitative analysis and comparison with conventional gastroscopy were performed. RESULTS: The images obtained with the postcontrast 3D coronal T1w-FLASH sequence were the most suitable in identifying gastric tumors. Complete correlation with conventional gastroscopy was achieved in 80% of the cases and partial correlation in 13% of the cases. The same imaging sequence was also appropriate for the evaluation of lymph nodes. For the identification of liver metastases, the images obtained with the axial postcontrast T1w 2D-FLASH sequence provided a higher diagnostic confidence as compared with other imaging protocols. CONCLUSIONS: Applying the dark lumen technique through MRI is suitable for imaging gastric tumors and has the potential to become a "one-stop shopping" method because of the possibility for lymph node evaluation and screening for metastases during the same session based on the same images.

Aged↗

Towards better informed consent in endoscopy: a study of information and consent processes in gastroscopy and flexible sigmoidoscopy.

OBJECTIVE: To determine the level of knowledge achieved by patients who have read a simple information sheet on gastroscopy and flexible sigmoidoscopy, and to determine the levels of information required by patients and solicitors specializing in clinical negligence. DESIGN: Self-administered questionnaires were sent to 516 patients in Leicester and 79 solicitors specializing in clinical negligence in England and Wales. The main objective outcome measures were the correct scores measured in a simple test of the content of information sheets about gastroscopy and flexible sigmoidoscopy. Other scores were based on the opinions of patients and solicitors on the type of information patients should receive and the levels of risk about which they should be informed. RESULTS: Of the clinical negligence specialists, 75%, compared with 44% of patients, felt that consent to procedures should be obtained 2 weeks before the test. In addition, 86% of solicitors felt that patients needed to be told about tests on at least two occasions and favoured booklets and videos. Both 48% of solicitors and 38% of patients felt that patients should be told of very uncommon risks, with 16% of clinical negligence specialists expecting patients to be told of risks of 1 in 1,000,000. The majority of patients (98%) and solicitors (95%) felt that patients should be formally tested as to whether they understand what they are told in the consent process. In an initial study of an information leaflet, South Asian patients had significantly poorer scores than English patients on formal testing of their knowledge of the leaflet's content. The poorest response (61% correct) was to a question including the word 'indigestion', which had been omitted from the information leaflet. Its inclusion led to a significant increase in the number answering the question correctly (96%). The positioning of a word in the list of reasons for doing the test was also important. In the flexible sigmoidoscopy leaflet, the word 'anaemia' was placed in the middle of a list of reasons for doing the test; only 85% answered the question correctly. In the sample of patients who received the modified gastroscopy leaflet, recall at 6 months was significantly impaired with most loss of memory being related to the purpose of the test. CONCLUSIONS: Consent needs to be supported by easy-to-read information and the patients' understanding needs to be formally tested. Important concepts must be included in this information as well as any uncommon risks of the procedure. In order to ensure that the information can be understood, the text should be reviewed by an experienced educationalist. If the text is to be used in a multicultural setting, it is important to ensure that patients for whom English is not their first language can easily understand it. The movement away from 'informed consent' towards an 'informed decision' process should facilitate these improvements.

Cultural Characteristics↗

Are patients' sedation preferences at gastroscopy influenced by preceding patients' decisions?

BACKGROUND: When patients choose sedation or no sedation for gastroscopy, it is unknown whether the decision and experience of preceding patients on the same endoscopy list influence such decisions. AIM: To address this question in an endoscopy unit, where pre- and postprocedure patients are free to communicate. METHODS: The order and sedation decisions of 503 out-patients attending diagnostic gastroscopy lists were analysed. One hundred patients completed a preprocedural questionnaire about sedation preferences. RESULTS: Three hundred and fifteen (63%) patients chose no sedation. Men were more likely to be unsedated, 170 (72%), than women 158 (59%) (chi(2) = 9.1, P < 0.01). Age did not influence decisions. If the first patient on an endoscopy list requested sedation, 36% of subsequent patients were also sedated. This was similar to 38% of subsequently sedated patients on lists where the first patient was unsedated. Similar proportions of subsequent patients requested sedation when comparing lists where the first two patients were both sedated or both unsedated and when comparing lists where the first three patients were all sedated or all unsedated. Ninety per cent of the patients completing preprocedural questionnaires had made sedation choices before arrival; the remaining undecided patients had unsedated endoscopies. CONCLUSIONS: Patients' sedation decisions are not influenced by preceding patients' decisions. Most patients attending for out-patient gastroscopy have already decided about sedation.

Choice Behavior↗

Responses of consecutive patients to reassurance after gastroscopy: results of self administered questionnaire survey.

OBJECTIVE: To study the time course and prediction of responses to reassurance after gastroscopy showing no serious illness. DESIGN: Selection of consecutive patients were assessed before gastroscopy, immediately after reassurance, and at follow up at 24 hours, 1 week, 1 month, and 1 year. Responses of subgroups of patients identified as high, medium, and low health anxiety by the health anxiety questionnaire were analysed. SETTING: Endoscopy clinic in a general hospital. INTERVENTION: Oral reassurance that there was "nothing seriously wrong." SUBJECTS: One consultant physician and 60 patients aged 18-74 referred for gastroscopy. MAIN OUTCOME MEASURES: Physician's and patients' ratings of the extent of the reassurance and patients' ratings of their anxiety about their health and of their illness belief. RESULTS: There was good agreement between the patients and the physician about whether reassurance had been given. Health anxiety and illness belief decreased markedly after reassurance. Patients with high health anxiety showed a significant resurgence in their worry and illness belief at 24 hours and 1 week, and these levels were maintained at 1 months and 1 year later. Patients with medium levels of health anxiety showed a reduction in worry and illness belief after reassurance, and this was generally maintained during follow up. Patients with low health anxiety maintained low levels of health worry and illness belief throughout the study. Partial correlation analyses showed that the levels of worry and illness belief after reassurance were predicted by the health anxiety questionnaire. This measure also had predictive value beyond that of a measure of general anxiety. CONCLUSIONS: Medical reassurance results in a reduction of worry about health and of illness belief, but this may be very short term. Measurable individual differences in health anxiety can be used to predict the response to reassurance.

Adolescent↗

Improving the detection rate of early gastric cancer requires more than open access gastroscopy: a five year study.

BACKGROUND/AIMS: To explore the reasons why patients with gastric cancer continue to present with advanced disease despite open access gastroscopy. PATIENTS: All patients diagnosed with gastric cancer between 1 August 1989 and 31 July 1994. METHODS: A retrospective study of the presentation of gastric cancer in South Tees; patients were diagnosed at open access gastroscopy or referred through conventional channels. Primary care records of 81 patients dying between 1991 and 1995 were analysed for previous symptoms, investigations, and antisecretory drug therapy. Findings were compared with 200 age and sex matched controls. RESULTS: The overall incidence of earlier stage gastric cancer remains low at 13%. Diagnostic delay occurs in both primary and secondary care due to a high incidence of previous dyspepsia and investigation. One in six patients had been previously investigated in the three years prior to diagnosis, the majority of whom were on antisecretory drugs. CONCLUSIONS: Early gastric cancer remains rare in South Tees health district. Advantages of open access gastroscopy appear to be compromised by delayed referral to hospital and failure of endoscopists to recognise the early disease; either they are unaware of its appearance or prior treatment with an H2 receptor antagonist masks the disease by allowing mucosal healing.

Aged↗

[Gastroscopy -- a routine procedure in the investigation of diseases of the stomach (author's transl)].

After a short review of the development of endoscopic investigations, the technique of gastroscopy is described and the indications for this procedure are pointed out. This procedure is of equal importance as radio-diagnostic measures in the routine investigation of stomach diseases and is of particular value when used as an emergency procedure and in the follow-up of patients after gastric operations. It also offers great advantages in the diagnosis of stomach tumours since biopsy material can be obtained from the lesion. Stomach haemorrhage due to gastric erosion, oesophagitis and the Mallory-Weiss syndrome are best diagnosed by gastroscopy. There are practically no contraindications to gastroscopy. The only precluding factor being an uncooperative patient. It is not contraindicated in patients with oesophageal varices or deformity of the spinal column. Complications are very rare. In the case of emergency gastrocscopy, shock must be counteracted and the blood pressure normalized before the investigation can be performed.

Emergencies↗

[Associated sedation of propofol and midazolam in small dosage and gastroscopy].

OBJECTIVE: To search for a sedative method that is more suitable for gastroscopy. METHODS: All of patients were randomly divided into control group and experimental group. The experimental group was treated with propofol and midazolam, the control group was treated with propofol alone. The cumulation dosage of propofol, sedative effect, variation of BP and SaO2 were observed in all patient. RESULTS: The cumulative dosage of propofol in the experimental group was lower than that in the control group [(73.21 +/- 18.67) mg and (117.23 +/- 21.57) mg respectively]; the oblivious degree in the experimental group was higher than that in the control group (95.65% and 80.00%); the onset time and the descendant range of BP and SaO2 were also lower in the experimental than those in the control group. There was not remarkable difference in sedative effect and veriviscont time between the control group and the experimental group. CONCLUSIONS: In such a rapid operation of gastroscopy, the dosage of propofol in the experimental group is obviously less than that in the control group, while it does not affect the effect of sedation, the diagnose and cure time in gastroscopy room, and has more security and less cost.

Adult↗

Results of emergency gastroscopy for acute upper gastrointestinal bleeding outside official hours at King Chulalongkorn Memorial Hospital.

This study was to evaluate the epidemiological characteristics, etiology and therapeutic outcome of active upper gastrointestinal bleeding in patients who underwent emergency gastroscopy outside official hours at the Gastroenterology Unit, King Chulalongkorn Memorial Hospital. From January to December 2002, 103 emergency gastroscopies were performed in 99 patients. There were 66 men and 33 women (mean age 55.4 years, range 22-98 years). Causes of bleeding were esophageal varices (29/99; 29.3%), gastric ulcer (25/99; 25.3%), duodenal ulcer (9/99; 9.1%), gastric varices (9/99; 9.1%) and miscellaneous (12/99; 12.1%). Etiology of bleeding was uncertain in 10.1 per cent of the cases. Therapeutic modalities for variceal bleeding were banding (78.6%), sclerotherapy (10.7%) and glue injection (10.7%). Endoscopic therapies for patients with non variceal bleeding were: epinephrine injection with bipolar coaptation (48.1%), epinephrine injection only (11.1%), bipolar coaptation alone (7.4%), heater probe (7.4%), epinephrine injection combined with heater probe (11.1%), epinephrine injection with bipolar coaptation and hemoclipping (7.4%), hemoclipping (3.7%), epinephrine injection with hemoclipping (3.7%). Initial hemostasis was achieved in 91.2 per cent of the patients (91/99). Recurrent bleeding within 72 hours developed in 9.1 per cent of patients (9/99). Of these, eight patients (88.9%) underwent re-endoscopy and bleeding was stopped in 62.5 per cent (5/8). And 2.0 per cent of patients (2/99) had to go for emergency surgery after failed therapeutic endoscopy. Overall mortality was 15.2 per cent (15/99). In conclusion, emergency gastroscopy can offer not only diagnostic but also therapeutic modality for patients with acute upper gastrointestinal bleeding. Endoscopic therapy is effective for both initial hemostasis and recurrent bleeding.

Adult↗

[Fiber gastroscopy in the diagnosis of gastroduodenal diseases and of primary cancer of the gastric stump in particular].

Data available in the literature are adduced and personal experience recorded with 5930 fiber gastroscopies, leading to the conclusion that fiber gastroscopy is a valuable method for diagnosis of diseases of the upper part of the gastrointestinal tract. Some aspects of primary cancer of the gastric residue and its inevitable accompanying pathology--the gastroduodenal reflux--are discussed, analyzing 313 fiber gastroscopies of patients, who had undergone in the past gastric resection for benign diseases. The authors adduce motives for the need of periodic fiber gastroscopic control of operated patients, aimed at early prophylaxis of primary cancer of the gastric residue. The need of regular medical control on these patients is also emphasized.

Duodenal Diseases↗

[Complaints after gastroscopy and their cause (author's transl)].

The various complaints after gastroscopy and the acceptability of the procedures are verified by a questionnaire in 300 consecutively examined patients with or without gastric lesions. The extent of psychic lability, neurosis and extraversion was determined by the Maudsley Personality Inventory test of Eysenck. The time necessary for the passage of the instrument (swallowing time) and the time taken by gastroscopy were registered on each patient. More than half of the patients complained of sore throat lasting more than 1 day. Less than a quarter had abdominal dyspepsia. The intensity of the sore throat was correlated with the swallowing time but not with the extent of neurosis or gastroscopy time. 98% of the patients consented to a control examination. The necessity of a gastroscope with less diameter and a non mucosal damaging top is stressed.

Adult↗

Gastroscopy.

Gastroscopy has become a safe and reliable procedure following the development of modern fibreoptic instruments which have replaced the semi-flexible gastroscope. Indications for gastroscopy may be diagnostic (to elucidate the nature of definite or indefinite radiological abnormalities, in persistent X-ray negative dyspepsia, post gastric surgery symptoms and upper gastrointestinal bleeding) or therapeutic (including polypectomy, electrocoagulation of bleeding points, papillotomy and removal of retained stones and the use of a laser beam to control bleeding). In can be done as an outpatient procedure with a low incidence of complications in experienced hands, but should be performed only in a properly equipped area with resuscitation facilities. Gastroscopy should form part of the routine investigation of patients with upper gastrointestinal problems where the appropriate indications are present.

Fiber Optic Technology↗

The value of gastroscopy in clinical diagnosis: a computer-assisted study.

The additional information obtained by gastroscopy in patients already examined by upper gastrointestinal roentgenography was assessed. For this purpose, a data sheet for computer analysis was filled in at the time of gastroscopy and again at patient dismissal. Overall, gastroscopy resulted in an altered diagnosis in 18 percent of 1, 368 examinations, and in another 7 percent of cases there were findings of possible clinical significance. Gastroscopic findings differed significantly from x-ray findings in 7 to 35 percent of cases, depending on the indication for the procedure.

Computers↗

[Importance of gastroscopy in chronic uremic patients (author's transl)].

In chronic uremic patient, two kinds of digestive troubles can occur: gastric or duodenal lesions secondary to an abnormal gastro-intestinal hormone excretion, and drug-induced disorders. Most of these manifestations were missed by usual barium meal and the use of routine endoscopic check-up can be particularly useful. We performed 70 gastroscopies in 67 chronic hemodialyze patients. Examinations were practiced immediately before dialysis with only a light sedation. We observed 39 lesions: 3 drug-induced gastritis, 15 erosive or pseudopolypoid inflammations of the polyric antrum, 2 gastric ulcers, 5 duodenal ulcers (two of them were linear), 2 peptic oesophagitis and 34 p. cent of our patients had marked duodenitis, most of these digestive abnormalities could be missed or overdiagnosed by using routine barium meal. In presence of the number and the therapeutic importance of these disorders, we think that a gastroscopy should be prescribed in three indications: uremic patients before the beginning of an hemodialyze treatment, chronic hemodialyze patients with unexplained anemia, check-up before renal transplantation where ulcerations are a major contra-indication. In such situations, gastroscopy seems an important progress for the management of this particular group of patients.

Adolescent↗

[Gastroscopy after gastric operations (author's transl)].

Gastroscopy after surgery of the stomach gives exact information about functional and morphological alterations. The aim of gastroscopy is to detect complications of the early postoperative period as well as of the later phase. Early diagnosis of gastric carcinoma after partial gastrectomy for benign lesions is only possible by routine gastroscopy.

Gastroscopy↗

Chronic nausea as the leading symptom: an indication for double-contrast examination of the upper intestinal tract following normal gastroscopy.

We report a patient with chronic nausea as the leading symptom of a primary carcinoma of the duodenum located at the flexura duodeno-jejunalis. The tumour was not reached at gastroscopy, which was performed twice. Since this area usually cannot be seen upon gastroscopy or upon small bowel enteroclysma according to Sellink, a double-contrast investigation of the upper gastrointestinal tract using a hypotonic agent should be performed when nausea persists although gastroscopy is normal.

Adenocarcinoma↗