the unusual angles and the movement from rapid respiration. Examination of the gastrointestinal lumen via openings in the abdominal wall began with the pioneering experiments of Beaumont2 on the exposed stomach of St. Martin in 1883. Stomal instrumentation for esophageal strictures was reported by Tucker3 in 1924. Diagnostic fiberoptic stomoscopy began with Wiendl et a1. 4 who performed fiberoptic endoscopy in 1971 for the pre-operative evaluation of lower esophageal patency through a gastrostomy stoma. Lightdale et aU in 1973 used a fiberoptic bronchoscope through gastrostomies in five patients without the need to dilate the gastrostomy stoma. In 1975, Schapira et aU described endoscopic examination of the stomach and proximal duodenum with retrograde cannulation of the ampulla of Vater. Cholangiography demonstrated choledocholithiasis and surgery was performed the next day. In our case, successful therapeutic endoscopic sphincterotomy and stone removal was carried out via gastrostomy in a patient otherwise unfit for major surgery. Robin Gray, MD Department of Radiology

Sebastian Leong, MBBS Norman Marcon, MD Gregory Haber, MD Division of Gastroenterology The Wellesley Hospital Toronto, Ontario, Canada

REFERENCES 1. Schapira L, Falkenstein DB, Zimmon DS. Endoscopy and ret-

2. 3. 4. 5.

rograde cholangiography via gastrostomy. Gastrointest Endosc 1975;22:103-4. Beaumont W. Experiments and observations on the gastric juice and the physiology of digestion. Plattsburg, New York: JP Allen, 1833. Tucker GF. Cicatricial stenosis of the esophagus with particular reference to treatment by continuous string bougienage with the author's bougie. Ann Otol Rhinol LaryngoI1924;3:1180-4. Wiendl HJ, Harlacher A, Stuchlik E. Ungewohnliche endoskopische Untersuchungstechnik zur praoperativen Diagnostik bei Osophagussriktur. Endoscopy 1972;4:51-3. Lightdale CJ, Posner G, Sherlock P, Winawer SJ. Fiberoptic stomoscopy. Gastrointest Endosc 1973;19:198.

Emergency sclerotherapy for esophageal variceal bleeding To the Editor: It is well known that there is a rapid fall in life-expectancy in patients with liver cirrhosis after bleeding or re-bleeding from esophageal varices. However, with the availability of safer surgical and non-surgical techniques to treat acute hemorrhagic episodes, the total survival rate is improving. At present, sclerotherapy seems to represent the best nonsurgical method both to control bleeding and to reduce rebleeding episodes. 1 , 2 Our experience with emergency sclerotherapy started in 1982, and within 9 years we treated 127 cirrhotic patients (90 men and 37 women, mean age 58.7) with a total number of 178 hemorrhagic episodes. At the first bleeding episode of variceal origin, we used fr~e hand technique and 1% polidocanol within 2 hours of hospital 732

admission (the average amount of sclerosant used was 40 ml; range, 15 to 85 mI). For this group of patients we assessed the mortality rate and the success rate for the procedure. Child's grade classification in these patients included 22 Child A (17.3%),48 Child B (37.8%), and 57 Child C (44.9%). The overall bleeding episodes were 178, of which 139 (78%) were from esophageal varices, 32 (17.9%) from gastric varices, and 7 (3.9%) from mucosal sloughs. Assessing mortality, we considered mortality directly due to bleeding episodes, within 24 hours, as failure of the procedure. Each bleeding episode was considered under control when we could achieve cessation of bleeding at the end of the endoscopy, associated with steady conditions in heart rate, blood pressure, and hematocrit in the following 24 hours. Every other hematemesis, following this interval, was considered to be a rebleeding episode. The overall success rate was 89.4% (98% at the end of the procedure), with 85.4% after first bleeding and 94.1% after re-bleeding. Others3- 5 have reported a cumulative success rate for acute bleeding between 90 and 95%. We observed a better success rate for the procedure in the Child B (98.4%) and Child A (93.1 %) groups, while the Child C group showed the worst success rate (81.3%). The total number of re-bleeding episodes during hospital admission (30 days) was 68. As expected, the number of rebleeding episodes increased with worsening Child's grade. The mean re-bleeding rate was 1.3 for Child A and for Child B, and 1.5 for Child C, respectively. After achieving hemostasis, 112 patients were subsequently submitted to weekly endoscopic sessions. We noted 34 (26.7%) deaths in the first 30 days: 15 (11.8%) patients died directly due to the first bleeding and 19 (16.9%) during the hospital admission for re-bleeding episodes or hepatic failure. Early re-bleeding recurrence was not associated with higher early mortality (x 2 = 1.55; P = not significant). With respect to Child's grade for the first bleeding, mortality occurred in 9 patients (15.7%) with Child C, 5 (10.4%) with ChildB, and 1 (4.5%) with ChildA. The overall hospital mortality rate was better in Child A (3 of 22 = 13.6%) and Child B (6 of 48 = 12.5%) than in the Child C group (25 of 57 = 43.8%). We conclude that esophageal variceal sclerosis using polidocanol injection remains safe and efficacious. Although Child C patients demonstrated a very bad prognosis and showed the highest liver failure, re-bleeding rate, and hospital mortality (43.8%), it was still possible to achieve cessation of bleeding in this group. In Child A and B patients, it seems unnecessary to employ other methods or chemical agents to arrest variceal bleeding, such as Histoacryl (Nbutyl-2-cyanoacrylat), since side effects are unpredictable and still unknown. 6- s On the other hand, Child C patients require new approaches. Esophageal ligation 9 may be most useful here, and its clinical application should be evaluated in randomized clinical trials. A. Paterlini, G. Lanzani, M. Graffeo, F. Buffoli, P. Cesari,

MD MD MD MD MD

GASTROINTESTINAL ENDOSCOPY

D. Benedini, MD A. Pascarella, MD F. Rolfi, MD Division of Gastroenterology S. Orsola FBF Brescia, Italy REFERENCES 1. Westaby D, Williams R. Status of sclerotherapy for variceal bleeding in 1990. Am J Surg 1990;160:32-6. 2. Terblanche J. Has sclerotherapy altered the management of patients with variceal bleeding? Am J Surg 1990;160:27-42. 3. Barsoum MS, Bolous FI, EI-Rooby AA, Rizk-Allah MA, Ibrahim AS. Tamponade and injection sclerotherapy in the management of bleeding oesophageal varices. Br J Surg 1982;69: 76-8. 4. Paquet K-J, Feussner H. Endoscopic sclerosis and esophageal balloon tamponade in acute hemorrhage from esophagogastric varices: a prospective controlled randomized trial. Hepatology 1985;5:580-3. 5. Larson AW, Cohen H, Zweiban B, et al. Acute esophageal variceal sclerotherapy: results of a prospective randomized controlled trial. JAMA 1986;255:497-500. 6. Soehendra N, Nam V, Grimm H, Kempeneers I. Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy 1986;18:25. 7. Feretis C, Tabakopoulos D, Benakis P, Xenofontos M, Golematis B. Endoscopic hemostasis of esophageal and gastric variceal bleeding with histoacryl. Endoscopy 1990;22:282-4. 8. Gotlib JP. Endoscopic obturation of esophageal and gastric varices with a cyanoacrylic tissue adhesive. Can J Gastroenterol 1990;4:637-8. 9. Stiegmann GV, Goff JS, Sun JH, Davis D, Bozdech J. Endoscopic variceal ligation: an alternative to sclerotherapy. Gastrointest Endosc 1989;35:431-4.

of erythromycin to smooth muscle motilin receptors. 3 ,4 This potent and rapid effect of intravenous erythromycin could be useful in other situations, such as in the preoperative state or before labor when there is a risk of regurgitation and aspiration. 5 Stanislas Chaussade, MD 'Phillipe Sogni, MD Daniel Couturier, MD Jean Guerre, MD Service d'Hepato-gastroenterologie Hopital Cochin Paris, France REFERENCES

1. Janssen J, Peeters TL, Vantrappen G, et al. Improvement of gastric emptying in diabetic gastroparesis by erythromycin. N Engl J Med 1990;322:1028-31. 2. Itoh Z, Nakaya M, Suzuki T, Arai H, Wakabayashi K. Erythromycin mimics exogenous motilin in gastrointestinal contractile activity in the dog. Am J Physiol (Gastrointestinal Liver Physiol10) 1984;247:G688-94. 3. Kondo Y, Torii K, Omura S, Itoh Z. Erythromycin and its derivatives with motilin-like biological activities inhibit the specific binding of 1251 motilin to duodenal muscle. Biochem Biophys Res Commun 1988;150:877-82. 4. Peeters TL, Matthijs G, Depoortere I, Cachet T, Hoogmartens J, Vantrappen G. Erythromycin is a motilin agonist. Am J Physiol (Gastrointestinal Liver Physiol 20) 1989;257:G470-4. 5. Scott D. Mendelson's syndrome. Br J Anaesthesia 1978;50: 977-8.

The disappearing colonic irrigation tube Intravenous erythromycin and delayed gastric emptying To the Editor: It has recently been shown that gastric emptying in diabetic patients with severe gastroparesis was accelerated by the use of intravenous doses of erythromycin in smaller doses than used for antibiotic therapy.' This effect was the consequence of the motilin-like effect of erythromycin. 2 We would like to report the acute effect of intravenous erythromycin in eight patients with severe delayed gastric emptying who were referred to an endoscopic unit for gastroscopy. There were two patients with diabetes mellitus, one patient with cirrhosis, and five patients with idiopathic gastroparesis, who had endoscopy for upper gastrointestinal symptoms. Esophagogastroduodenoscopy (Olympus XQ20) showed the presence of retained food in the stomach which prevented a complete examination. An intravenous infusion of erythromycin was carried out immediately (150 mg during a 20-min period) and a second gastroscopy was promptly performed. In each case, the stomach was without a trace of food residue. This study demonstrates that intravenous erythromycin dramatically accelerates gastric emptying in patients with delayed gastric emptying and gastric stasis. This effect can be attributed to the motilin agonist property of erythromycin. 2 Recent in vitro studies have shown that erythromycin is a potent agonist of motilin and that its action on the upper gastrointestinal tract is a direct result of the binding VOLUME 38, NO.6, 1992

To the Editor: Foreign bodies in the gastrointestinal tract usually occur as a result of accidental or intentional ingestion. Most foreign bodies are found in the upper gastrointestinal tract with the esophagus being the most common." 2 Foreign bodies of the lower gastrointestinal tract have also been reported in the literature, with the rectum being the most common. 3- 6 I wish to report a case of a disappearing colon cleansing tube used by a patient with a colostomy for irrigation during hydrotherapy. A 68-year-old man had abdomino-perineal resection with a descending colostomy for adenocarcinoma of the rectum 16 years ago. An upper gastrointestinal series, small bowel series, and a barium enema obtained 6 years ago for intermittent abdominal pain were normal. He became asymptomatic soon thereafter. Recently, he was referred for a surveillance colonoscopy. He had been performing colonic irrigation twice weekly since the surgery. He was advised to stop the irrigation but was reluctant to do so because he believed that the colonic hydrotherapy was an important therapeutic measure to prevent subsequent colon cancer. A colonoscopy performed through the colostomy was unremarkable except for diverticula. Six weeks later, he was seen in the emergency room because his colon irrigation tube had disappeared into the colon during irrigation 18 hours earlier. He had performed the colon irrigation by connecting the irrigation tube (30em length, 24 F) to the matching connector tube and irrigator drain (Hollister'"; Hollister Inc., Libertyville, Ill.) con733