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A 61-year-old, bronchitic male developed respiratory failure due to a pneumoperitoneum following gastroscopy. The management of this case and the possible complications following gastroscopy are described and discussed.
The effects of intramuscular injections on plasma creatine kinase (CK), aspartate amino-transferase, lactate dehydrogenase, and hydroxybutyrate dehydrogenase concentrations were examined in 19 patients given intramuscular premedication for gastroscopy, and 18 patients given other intramuscular injections. Only CK concentrations showed significant increases which were as high as four times the upper limit of normal, and affected a maximum of 51% of patients at 12 hours after the first injection. Elevated CK concentrations persisted for up to 72 hours, and followed injections of diazepam, various antibiotics, and the combination of a narcotic analgesic with atropine. Gastroscopy did not appear to increase plasma enzyme concentrations in six patients who were given intravenous premedication. The significance of these findings to the diagnosis of myocardial infarction is discussed.
BACKGROUND: We tested the hypothesis that pediatric gastroscopy is more successful using the ProSeal laryngeal mask airway with the drain tube as a conduit to the stomach (ProSeal LMA group) than using nasal cannulae with conventional oral access to the stomach (NC group). METHODS: Sixty children were consecutively and randomly allocated into each group. Patients breathed spontaneously and were given sevoflurane/air/oxygen mixture with propofol 1 mg.kg-1 boluses, as required. Anesthesia was provided by experienced users of both techniques. The following data were collected by an unblinded observer: operation and anesthesia times; cardiorespiratory data; adverse events; and recovery scores. In addition, the surgeon scored the ease of performing the procedure. RESULTS: The mean (range) age and weight was 74 (24-144) months and 26 (10-61) kg. Operation (15 min vs 24 min, P<0.0001) and anesthesia (22 min vs 37 min, P<0.0001) times were shorter in the ProSeal LMA group, but propofol bolus requirements per unit time were similar. Oxygen saturation was higher in the ProSeal LMA group (100% vs 94%, P<0.0006), but other cardiorespiratory variables were similar. There were no differences in the ease of performing the procedure. Hypoxia occurred more frequently in the NC group (20% vs 0%). Recovery scores were similar. CONCLUSIONS: We conclude that pediatric gastroscopy is quicker and has fewer airway complications when performed through the ProSeal LMA than using nasal cannulae and a conventional approach by experienced users.
BACKGROUND: Before endoscopy patients undergo an uncomfortable fluid fast to reduce the risk of gastric acid aspiration and to ensure good endoscopic views are obtained. However, fluids rapidly leave the stomach and thus a long fluid fast before endoscopy may not be required. AIMS: The object of this study was to establish whether drinking before endoscopy is safe and relieves patients' symptoms of thirst. PATIENTS AND METHODS: 88 patients with American Society of Anaesthesiologists classification of physical status grades I and II were recruited in a controlled randomised single blind trial. The volume and pH of gastric aspirate obtained at gastroscopy was assessed in patients who drank 330 ml of water a minimum 90 minutes before their endoscopy and compared with values in patients who starved overnight. RESULTS: 44 patients who drank ('drinkers') 330 ml of water a mean 117 minutes before their morning gastroscopy had a similar volume and pH of gastric aspirate compared with 44 patients starved overnight ('starvers'); median volume 12.5 ml versus 10 ml, median pH 2.0 versus 2.0; 'drinkers' versus 'starvers' (NS). Before endoscopy patients were asked to score their thirst and hunger ratings as either none, mild, moderate or severe. Ratings for moderate and severe thirst were grouped together for analysis. The percentage of drinkers compared with starvers in each group with no thirst, mild thirst, and moderate severe thirst was 63%, 46%, and 37% respectively (chi 2 test for trend p < 0.05). Hunger ratings were similar in the two groups. CONCLUSIONS: It is safe for elective day cases to drink a significant volume of water two hours before endoscopy and this alleviates symptoms of thirst.
A total of 124 subjects who were undergoing routine endoscopy were randomly assigned to one of three groups. All three groups received lignocaine throat spray. The first group additionally received midazolam, the second received hypnosis, whilst the third only received lignocaine throat spray. Although hypnotized patients were deemed by an independent observer to be less agitated than the other two groups (p < 0.03), they reported the gastroscopy to be significantly more uncomfortable (p < 0.042) and scored higher in their memory for the procedure (p < 0.001). They also took slightly longer to induce than the midazolam group. The midazolam group on the other hand rated the procedure as significantly more comfortable although paradoxically were seen by an independent observer as being more agitated. They were also significantly more amnesic. The endoscopist encountered more procedural difficulties with this group but this did not reach levels of significance. Hypnosis was not shown to be an effective alternative to intravenous sedation in gastroscopy.
Flexible fiberoptic endoscopes are being used increasingly for direct visualization and biopsy of lesions in the upper gastrointestinal tract. Contrary to earlier expectations, however, the incidence of complications has not diminished despite the technical advantages of modern flexible instruments over semirigid endoscopes; indeed, the mortality of fibergastroscopic perforation has almost quadrupled compared to standard gastroscopy. The authors cite their experience with the spectrum of complications associated with fiberoptic esophagoscopy and gastroscopy. Radiological recognition and evaluation of these iatrogenic incidents is of paramount importance.
Thirty-seven patients underwent gastroscopy under pharyngeal anaesthesia with benzocaine-tetracaine (Endospray; Axcan Pharma). Patients recorded their perception of intubation, of the rest of the procedure, of taste and of throat well-being on visual analogue scales. Throat well-being and taste scores were better for men than for women. There was a strong trend for smokers to be more intolerant to intubation than nonsmokers. There was a weak but significant correlation for younger patients to be more intolerant to intubation. This study points to age and smoking status as possible factors influencing the perception of gastroscopy under pharyngeal anesthesia.
The age-adjusted incidence of stomach cancer has been studied during the introduction of gastroscopy service in Norway. The incidence showed an annual decrease of 3.5% for both sexes. More cases were classified within anatomic subsites. For men there was a decreasing incidence for cancers located in the antrum, for extensive tumours and for not otherwise specified (NOS) disease. No significant changes were found for cancer of the body or the cardia/fundus. In women a decrease in incidence was noted for the NOS subgroup, an increase was seen for tumours of the gastric body, and no significant changes were found for antral cancers or for tumours of the cardia/fundus. A marked increase in incidence was noted for gastric stump cancers for both sexes. During this period a shift in staging towards less advanced disease occurred. In conclusion, the increased diagnostic accuracy and the shift in staging of the disease may suggest that the introduction of gastroscopy service has been effective.
AIM: To evaluate spiral computed tomography (CT) including virtual gastroscopy for diagnosis of gastric carcinoma in comparison with upper gastrointestinal series (UGI), fiberoptic gastroscopy (FG) and histopathology. METHODS: Sixty patients with histologically proven gastric carcinoma (54 advanced and 6 early) were included in this study. The results of spiral CT were compared with those of UGI and FG. Two observers blindly evaluated images of spiral CT and UGI and video recording of FG with consensus in terms of diagnostic confidence with a five-point scale. Sensitivities of lesion detection, Borrmann's classification of spiral CT, UGI and FG, as well as the accuracy of TNM staging of spiral CT were determined by comparing them to surgical and histological findings. RESULTS: The lesion detection rate was 98 % (59/60), 95 % (57/60) and 98 % (59/60) for spiral CT, UGI and FG, respectively. There were no statistical differences in the detection sensitivity among the three techniques (P>0.05). For the sensitivity in Borrmann's classification, spiral CT was higher than that of UGI (P=0.025) and similar to that of FG (P>0.05). The accuracy of spiral CT in staging the gastric carcinoma was 76.7 %. Six cases of early gastric carcinoma were all detected by spiral CT as well as FG. CONCLUSION: Spiral CT is equivalent to UGI and FG in the detection of gastric carcinoma, and superior to UGI but similar to FG in the Borrmann's classification of advanced gastric carcinoma. Spiral CT is more valuable than FG in the staging of gastric carcinoma.
The examinations were performed in 418 patients with malignancy or an ulcer of the stomach. In all cases the Cancer Registry of Norway was asked for the final diagnosis and date of death. The diagnosis of malignancy was based on histology on operated or autopsy specimens, and the surviving cases were re-examined by answering a questionnaire. At the time of the primary examination a total of 103 cases of malignancies were found, of whom 41 were women. 84 patients had not been operated on previously. Among these 7 cases of early carcinoma were found. In 19 patients a partial gastrectomy had been performed. A false diagnosis of benign lesion was given on biopsy in 2 per cent, by gastroscopy in 8, and by X-ray examination in 31 per cent. A definite diagnosis of malignancy was made correctly by the same procedures in 95, 53 and 16 per cent, respectively. After 30 months of observation 16 cases of malignant lesions were reported among the patients (315) who had an ulcer of the stomach with benign histology on directed biopsy at the primary examination. A false benign diagnosis had been made in 33 per cent of 119 with malignancy by X-ray examination, in 10 per cent by gastroscopy, and in 15 per cent by histology on biopsy. The corresponding percentages in the total material of cases with benign and malignant lesions were 10.2, 2.9, and 4.3, respectively. In cases with previous partial gastrectomy, and in those with early cancers much higher rates of false negative diagnosis of malignancy has so far been suggested in 12 per cent of cases with benign ulcers, a gastroscopical diagnosis has been suggested in 22 per cent, and a bioptical in none. A combination of diagnostic procedures provided a correct diagnosis of malignancy in 118 out of 119 patients.
INTRODUCTION: The aim of this study was to investigate whether guidelines for selecting dyspeptic patients for early endoscopy are appropriate and whether referrals from general practitioners give all necessary information. MATERIALS AND METHODS: We carried out a prospective study of consecutive referrals from general practitioners. The patients were referred by general practitioners to the Department of Medical Gastroenterology, Aalborg Hospital, during the period 1 February 1999 to 31 December 1999. The referrals for endoscopy were examined for information about the duration of symptoms, alarm symptoms (anaemia, dysphagia, vomiting, and weight loss), usage of ASA/NSAID, and medical treatment with acid-suppressants. At endoscopy, similar information was recorded on a standardised form for comparison. RESULTS: Two hundred and ninety-nine patients, 150 men and 149 women, were entered in the study. The medium age was 51.3 years (17-95). Ninety-six (32%) patients had organic dyspepsia (ulcer, oesophagitis, cancer). Of 192 (46%) patients selected for early gastroscopy, 88 (46%) were assigned to early examination solely because of age > 45 years, and 21 (11%) solely because of alarm symptoms. All the patients with information about ASA/NSAID medication were older than 45 years. The diagnosis of cancer and ulcer was significantly more often found in the group of patients selected for early gastroscopy 31/192, as compared with the waiting list patients 9/107 (p = 0.004). DISCUSSION: The guidelines for distribution to early and waiting list endoscopy proved to be well suited for priority selection of patients with the highest risk of organic dyspepsia.
A total of 184 specimens from gastroscopy were studied using Fourier transform infrared (FTIR) spectroscopy. The spectra of small-sized gastric endoscope samples with high quality were measured using the modified FTIR spectrometer with a MCT detector. The results show that the spectra of chronic superficial gastritis are similar to those of the normal block tissue in our previous study. But there are significant differences in band location and relative intensity between the spectra of chronic superficial gastritis and those of normal gastric tissues. Similarly, the differences exist in the spectra of chronic atrophic gastritis and those of malignant gastric tissues. In addition, the subtraction technique can provide more information to identify well the gastric samples of chronic atrophic gastritis, superficial gastritis and gastric cancer from endoscope the detection. These results indicate that FTIR spectroscopy exhibits potential to diagnose the gastric samples from gastroscopy.
Premedication for gastroscopies is still controversial. Most gastroenterologists use premedication routinely, often without control of vital signs. However, even if rarely, serious (mainly cardiorespiratory) complications still occur. In 101 patients in whom a gastroscopy had been performed, oxygen saturation before, during and after the endoscopy was investigated. A fall in saturation was seen in most of the patients but was usually minor. However, severe hypoxemia occurred in some patients, especially if premedication was used. Older patients and patients with severe anemia were particularly at risk. These results emphasize that premedication should not be used without precaution and special surveillance, especially in high risk patients. Prophylactic oxygen administration significantly diminishes the risk.
Transient bacteremia during and after endoscopic procedures is a well-documented phenomenon. Streptococcus viridans peritonitis is frequently associated with peritoneal dialysis, and the infection is probably attributable to hematogenous spread, dental procedures, or transluminal contamination with oral flora. To our knowledge, no reports exist of peritonitis occurring after gastroscopy in peritoneal dialysis patients. Here, we report the case of a 69-year-old male patient receiving automated peritoneal dialysis who required emergency gastroscopy and sclerotherapy plus heat-probe coagulation to control active bleeding from a duodenal ulcer The next day, this patient developed nausea and abdominal pain. The diagnosis of peritonitis was made based on a cloudy peritoneal effluent and a leukocyte count of 11,500 cells/microL with 98% neutrophils. S. viridans was identified in the peritoneal fluid culture. The patient received ceftazidime for 14 days, followed by clarithromycin for 7 days, and he recovered successfully. Patients receiving peritoneal dialysis who undergo esophagogastroduodenal endoscopy are at risk to develop peritonitis, and so antibiotic prophylaxis is desirable.
A material of 100 patients aged 18-70 years, ASA groups 1-2, who were otherwise healthy with slight generalized sequelae of their illness but without limitations in their usual habits, who were admitted for gastroscopy were randomized to sedation with either diazepam or propofol. Prior to the examination, 0.2 mg/kg diazepam or 1 mg/kg propofol was administered. If necessary, this was supplemented with half of the initial dosage. No difference were found in the sedation. Patients in the propofol group remembered the surgeon's information significantly better and woke significantly more rapidly. Propofol caused significantly more pain on injection. We consider that propofol can be employed for outpatient gastroscopy.
In two double-blind, randomized trials the efficacy and safety of flumazenil, the first benzodiazepine antagonist, were assessed in 100 adult patients undergoing gastroscopy under diazepam or midazolam sedation. The criteria of efficacy were the degree of sedation and anterograde amnesia. The median gastroscopy time was 20 min (range 5-40 min). The diazepam group received median 30 mg (range 15-60 mg) Diazemuls and the midazolam group median 15 mg (range 10-40 mg) Dormicum. Both groups were antagonized by median 0.42 mg flumazenil (range 0.4-0.6 mg). There was no inter-group difference with regard to blood pressure, heart rate and respiration rate. There was a significantly faster recovery of the patients after injection of flumazenil than after placebo. Patients were awake shortly after flumazenil, but remained drowsy or asleep after placebo administration. All patients, regardless of diazepam or midazolam sedation, antagonized with flumazenil were awake within 5 min and remained awake during the whole observation period of 3 h. The amnesia was totally eliminated by flumazenil. There were no significant differences in side-effects between the groups.
One hundred and twenty-seven patients with gastric tumor or precancerous diseases were examined by gastroscopy plus cytology, and the results were compared with that of histopathology after operation. Out of 127 cases, 70 were diagnosed as gastric cancer (15 cases as early cancer, 55 as advanced cancer). The positive rate for early cancer was 21.4%, it comprised 11.2% of all gastric cancers diagnosed by gastroscopy during the same period. The preoperative positive rate of early gastric cancer was 100% (13/13) as examined by the combination of touch, brush cytology and mucosal biopsy. The combined method may increase the positive rate and the accuracy, not only for advanced but also for early gastric cancers. It is suggested that the combination of these methods be routinely used in the diagnosis of suspicious cancer in the gastric mucosa.
Gastric rinsing during gastroscopy is presented as a new, effective, uncomplicated method of primary elimination of poison, as a part of a new diagnostic and therapeutic concept for patients intoxicated with hypnotics. The advantage of this active therapy is a fast elimination of the toxic substance and prevention of secondary complications. The diagnostic value of gastroscopy and radiological examination in patients with unexplained comatous states is emphasized.