University Departments of Anaesthesia and Surgery Glasgow Royal Infirmary Glasgow, Scotland
REFERENCES 1. Berman IR, Fleischer D. Monitoring and patient safety. Gastrointest Endosc 1990;36:160-1.
2. Murray AM, Morran CG, Kenny GNC, Anderson JR. Arterial oxygen saturation during upper gastrointestinal endoscopy: the effects of a midazolam/pethidine combination. Gut 1990;
(12%), however, prevents us from endorsing the indiscriminate use of PCPT. We have found that the anatomy of the intramural choledochus cannot be accurately predicted. Therefore, blind puncture of the papillary roof with the extension of the precut incision inferiorly as described by Siegel et al. l is a very risky procedure. We agree that PCPT should only be used in highly selected cases and by endoscopists experienced in this technique. Massimo Conio, Sebastiano Saccomanno, Hugo Aste, Vittorio Pugliese,
31:270-3.
3. Eichorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA 1986;256:1017-20. 4. Lunn JL, ed. Recommendations for Standards of Monitoring during Anaesthesia and Recovery. The Association of Anaesthetists of Great Britain and Ireland. 1988;1:1.
MD MD MD MD
Istituto Nazionale per la Ricerca sui Cancro Servizio di Gastroentero/ogia et Endoscopia Digestiva Genova, Italy
REFERENCES
Precut papillotomy: primum non nocere To the Editor: It was with great interest that we read the paper of Siegel et al. l and the editorial by Cotton 2 concerning precut papillotomy (PCPT). At the time we applied PCPT, we had performed nearly 2000 diagnostic and therapeutic ERCPs. Our ability to cannulate the common bile duct (CBD) was between 85 and 90% comparable to that reported in the literature. 3 To date, we have performed PCPT in 16 patients (age range, 63 to 94 years; median age, 81 years). All were referred to our unit because of clinical and laboratory evidence of obstructive jaundice, and all had dilation of the CBD on ultrasound scanning. The papilla of Vater and the peripapillary area were normal in all but one patient, whose bulging papilla contained an impacted stone. The PCPT was done according to the technique described by Huibregtse et al. 4 with a retractable, 5-mm-long needle knife. In 11 (69%)cases, precut was immediately followed by CBD cannulation. Stones were present in eight cases and completely removed in all of them; pancreatic cancer was diagnosed in three patients, and two were successfully decompressed with stents. One patient was cannulated after a second attempt, thereby increasing the rate of successful cannulation from 69 to 75%. However, extraction of a CBD stone was not possible, and the patient was referred to surgery. Cannulation failed in four (25%) patients. Of these, two patients elected to have surgery; one was found to have a CBD stone, and the other was found to have pancreatic cancer. Two (12%) other patients suffered complications. One with pancreatic cancer succumbed to gram-negative sepsis 24 hours after PCPT, giving a mortality rate of 6%. The other, with the CBD stone, developed a duodenal perforation and was treated surgically. Our small retrospective study reveals that PCPT can yield a correct diagnosis in 75 % of the cases and permits successful therapeutic intervention in 69%. Although our experience was limited to one patient, we found that impacted stones lend themselves to this type oftherapy because they provide a protective surface on which the precut papillotome can be aligned, thereby permitting a more controlled and limited incision. The high incidence of morbidity and mortality 544
1. Siegel JH, Ben-Zvi JS, Pullano W. The needle knife: a valuable
tool in diagnostic and therapeutic ERCP. Gastrointest Endosc 1989;35:499-503.
2. Cotton PB. Precut papillotomy-a risky technique for experts only. Gastrointest Endosc 1989;35:578-9. 3. Siegel JH. Precut papillotomy: a method to improve success of ERCP and papillotomy. Endoscopy 1981;12:130-3. 4. Huibregtse K, Katon RH, Tytgat GNJ. Precut papillotomy via fine-needle knife papillotome: a safe and effective technique. Gastrointest Endosc 1986;32:403-5.
Endoscopic diagnosis of intestinal metaplasia To the Editor: Intestinal metaplasia is frequently associated with gastric mucosal atrophy. Gastric atrophy may be suggested at the time of endoscopy, but intestinalization is a diagnosis that requires specialized endoscopic staining techniques or pathologic study. We would like to present the endoscopic findings in a patient whose gastric mucosal appearance suggested, and pathologic examination confirmed, intestinal metaplasia. A 76-year-old woman was referred for evaluation of several months of anorexia, early satiety, occasional vomiting, and weight loss. She had a remote history of peptic ulcer disease treated with antacids, without known recurrence. Physical examination was unrevealing as were routine laboratory studies. Esophagogastroduodenoscopy revealed a normal esophagus and proximal stomach. The stomach distended well with soft, pliable mucosal folds. The mucosa of the gastric body was characterized by numerous, evenly distributed, small (1mm) white elevations separated by pale orange mucosa (Fig. 1). The antral mucosa was erythematous but otherwise visually normal. The duodenal bulb and second portion were normal in appearance. Multiple biopsies of the gastric body (Fig. 2) revealed marked loss of gastric glands with widespread intestinal metaplasia. Small foci of inflammatory cells were noted without evidence of dysplasia or carcinoma. Antral biopsies revealed regenerative hyperplasia, and a biopsy from the duodenum was normal. GASTROINTESTINAL ENDOSCOPY
raising the possibility of antacid adsorption onto villous surfaces as a possible cause of this mucosal appearance. 3 The mucosal projections and villous-like projections seen by light microscopy in intestinilized mucosa correspond to undulating interconnecting ridges of mucosa with intervening depressions (the openings of intestinal glands) as seen by electron microscopy and are not true villi" This appearance, when viewed at endoscopy, should alert the endoscopist to the possible presence of intestinal metaplasia, which warrants pathologic confirmation. George Stathopoulos, MD Ruth D. Goldberg, MD Michael O. Blackstone, MD Departments of Medicine (Section of Gastroenterology) and Pathology University of Chicago Chicago, Illinois
REFERENCES
Figure 1. Endoscopic appearance of gastric body revealing numerous, evenly distributed 1-mm white mucosal projections.
1. Meshkinpour H, Orlando RA, Arguello JF, et al. Significance of endoscopically visible blood vessels as an index of atrophic gastritis. Am J Gastroenterol 1979;71:376-9. 2. Ida K, Hashimoto Y, Kawai K. In vivo staining of gastric mucosa: its application to endoscopic diagnosis of intestinal metaplasia. Endoscopy 1975;7:18-24. 3. Blackstone MO. Endoscopic interpretation. New York: Raven Press, 1984. 4. Winborn WB, Wesser E. Scanning electron microscopy of intestinal metaplasia of the human stomach. Gastrointest Endosc 1983;27:201-7.
Pyogenic arthritis of the knee following Nd:VAG laser destruction of an
esophageal cancer To the Editor:
Figure 2. Light microscopy of biopsy from gastric body. The gastric mucosa is characterized by atrophy of gastric glands, foci of inflammation, and diffuse intestinal metaplasia, with villous-like projections of the mucosal surface (original magnification x 120).
Gastric mucosal atrophy may be suggested endoscopically by the presence of prominent submucosal blood vessels in the body and fundus.' Intestinal metaplastic change generally requires special endoscopic staining techniques or pathologic study. Methylene blue, when applied to the mucosa at the time of endoscopy, selectively stains intestinilized mucosa (as opposed to normal or cancerous mucosa) blue. 2 The endoscopic appearance of our patient's gastric mucosa with intestinalization has, to our knowledge, not been reported. This appearance is reminiscent of a granular duodenum that is sometimes seen in patients with peptic ulcer disease. These patients had been treated with antacids, VOLUME 36, NO.5, 1990
Palliation of inoperable esophageal carcinoma now includes endoscopic laser ablation. Experience with the Nd:YAG laser in treating patients with these tumors has shown laser therapy to be both safe and effective.' We report the complication of pyogenic arthritis of the knee after Nd:YAG laser destruction of an obstructing esophageal cancer. A 69-year-old man was seen in May 1989 with a I-month history of dysphagia. Endoscopy and biopsy revealed an exophytic esophageal adenocarcinoma at 30 cm. Laparotomy with a view to resecting the tumor was abandoned because of the presence of metastatic deposits in celiac lymph nodes on frozen section. Palliation of the dysphagia was achieved by Nd:YAG laser therapy on three occasions (June 5, 12, and 26) with necrosis and destruction of the exophytic cancer. Esophageal dilation was not used, and the laser energy employed on each occasion was similar. Two weeks after the last laser treatment, the patient returned with a lO-day history of a swollen, painful left knee. There was no history of trauma, arthritis, or gout. On examination, the patient was febrile (38°C), with a swollen, red, hot, tender knee containing a large effusion. Radiology of the knee revealed gas within the large effusion. Under aseptic conditions, 200 ml of pus were aspirated from the knee, and the patient was started on gentamicin 545
REFERENCES 1. Berman IR, Fleischer D. Monitoring and patient safety. Gastrointest Endosc 1990;36:160-1.
2. Murray AM, Morran CG, Kenny GNC, Anderson JR. Arterial oxygen saturation during upper gastrointestinal endoscopy: the effects of a midazolam/pethidine combination. Gut 1990;
(12%), however, prevents us from endorsing the indiscriminate use of PCPT. We have found that the anatomy of the intramural choledochus cannot be accurately predicted. Therefore, blind puncture of the papillary roof with the extension of the precut incision inferiorly as described by Siegel et al. l is a very risky procedure. We agree that PCPT should only be used in highly selected cases and by endoscopists experienced in this technique. Massimo Conio, Sebastiano Saccomanno, Hugo Aste, Vittorio Pugliese,
31:270-3.
3. Eichorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA 1986;256:1017-20. 4. Lunn JL, ed. Recommendations for Standards of Monitoring during Anaesthesia and Recovery. The Association of Anaesthetists of Great Britain and Ireland. 1988;1:1.
MD MD MD MD
Istituto Nazionale per la Ricerca sui Cancro Servizio di Gastroentero/ogia et Endoscopia Digestiva Genova, Italy
REFERENCES
Precut papillotomy: primum non nocere To the Editor: It was with great interest that we read the paper of Siegel et al. l and the editorial by Cotton 2 concerning precut papillotomy (PCPT). At the time we applied PCPT, we had performed nearly 2000 diagnostic and therapeutic ERCPs. Our ability to cannulate the common bile duct (CBD) was between 85 and 90% comparable to that reported in the literature. 3 To date, we have performed PCPT in 16 patients (age range, 63 to 94 years; median age, 81 years). All were referred to our unit because of clinical and laboratory evidence of obstructive jaundice, and all had dilation of the CBD on ultrasound scanning. The papilla of Vater and the peripapillary area were normal in all but one patient, whose bulging papilla contained an impacted stone. The PCPT was done according to the technique described by Huibregtse et al. 4 with a retractable, 5-mm-long needle knife. In 11 (69%)cases, precut was immediately followed by CBD cannulation. Stones were present in eight cases and completely removed in all of them; pancreatic cancer was diagnosed in three patients, and two were successfully decompressed with stents. One patient was cannulated after a second attempt, thereby increasing the rate of successful cannulation from 69 to 75%. However, extraction of a CBD stone was not possible, and the patient was referred to surgery. Cannulation failed in four (25%) patients. Of these, two patients elected to have surgery; one was found to have a CBD stone, and the other was found to have pancreatic cancer. Two (12%) other patients suffered complications. One with pancreatic cancer succumbed to gram-negative sepsis 24 hours after PCPT, giving a mortality rate of 6%. The other, with the CBD stone, developed a duodenal perforation and was treated surgically. Our small retrospective study reveals that PCPT can yield a correct diagnosis in 75 % of the cases and permits successful therapeutic intervention in 69%. Although our experience was limited to one patient, we found that impacted stones lend themselves to this type oftherapy because they provide a protective surface on which the precut papillotome can be aligned, thereby permitting a more controlled and limited incision. The high incidence of morbidity and mortality 544
1. Siegel JH, Ben-Zvi JS, Pullano W. The needle knife: a valuable
tool in diagnostic and therapeutic ERCP. Gastrointest Endosc 1989;35:499-503.
2. Cotton PB. Precut papillotomy-a risky technique for experts only. Gastrointest Endosc 1989;35:578-9. 3. Siegel JH. Precut papillotomy: a method to improve success of ERCP and papillotomy. Endoscopy 1981;12:130-3. 4. Huibregtse K, Katon RH, Tytgat GNJ. Precut papillotomy via fine-needle knife papillotome: a safe and effective technique. Gastrointest Endosc 1986;32:403-5.
Endoscopic diagnosis of intestinal metaplasia To the Editor: Intestinal metaplasia is frequently associated with gastric mucosal atrophy. Gastric atrophy may be suggested at the time of endoscopy, but intestinalization is a diagnosis that requires specialized endoscopic staining techniques or pathologic study. We would like to present the endoscopic findings in a patient whose gastric mucosal appearance suggested, and pathologic examination confirmed, intestinal metaplasia. A 76-year-old woman was referred for evaluation of several months of anorexia, early satiety, occasional vomiting, and weight loss. She had a remote history of peptic ulcer disease treated with antacids, without known recurrence. Physical examination was unrevealing as were routine laboratory studies. Esophagogastroduodenoscopy revealed a normal esophagus and proximal stomach. The stomach distended well with soft, pliable mucosal folds. The mucosa of the gastric body was characterized by numerous, evenly distributed, small (1mm) white elevations separated by pale orange mucosa (Fig. 1). The antral mucosa was erythematous but otherwise visually normal. The duodenal bulb and second portion were normal in appearance. Multiple biopsies of the gastric body (Fig. 2) revealed marked loss of gastric glands with widespread intestinal metaplasia. Small foci of inflammatory cells were noted without evidence of dysplasia or carcinoma. Antral biopsies revealed regenerative hyperplasia, and a biopsy from the duodenum was normal. GASTROINTESTINAL ENDOSCOPY
raising the possibility of antacid adsorption onto villous surfaces as a possible cause of this mucosal appearance. 3 The mucosal projections and villous-like projections seen by light microscopy in intestinilized mucosa correspond to undulating interconnecting ridges of mucosa with intervening depressions (the openings of intestinal glands) as seen by electron microscopy and are not true villi" This appearance, when viewed at endoscopy, should alert the endoscopist to the possible presence of intestinal metaplasia, which warrants pathologic confirmation. George Stathopoulos, MD Ruth D. Goldberg, MD Michael O. Blackstone, MD Departments of Medicine (Section of Gastroenterology) and Pathology University of Chicago Chicago, Illinois
REFERENCES
Figure 1. Endoscopic appearance of gastric body revealing numerous, evenly distributed 1-mm white mucosal projections.
1. Meshkinpour H, Orlando RA, Arguello JF, et al. Significance of endoscopically visible blood vessels as an index of atrophic gastritis. Am J Gastroenterol 1979;71:376-9. 2. Ida K, Hashimoto Y, Kawai K. In vivo staining of gastric mucosa: its application to endoscopic diagnosis of intestinal metaplasia. Endoscopy 1975;7:18-24. 3. Blackstone MO. Endoscopic interpretation. New York: Raven Press, 1984. 4. Winborn WB, Wesser E. Scanning electron microscopy of intestinal metaplasia of the human stomach. Gastrointest Endosc 1983;27:201-7.
Pyogenic arthritis of the knee following Nd:VAG laser destruction of an
esophageal cancer To the Editor:
Figure 2. Light microscopy of biopsy from gastric body. The gastric mucosa is characterized by atrophy of gastric glands, foci of inflammation, and diffuse intestinal metaplasia, with villous-like projections of the mucosal surface (original magnification x 120).
Gastric mucosal atrophy may be suggested endoscopically by the presence of prominent submucosal blood vessels in the body and fundus.' Intestinal metaplastic change generally requires special endoscopic staining techniques or pathologic study. Methylene blue, when applied to the mucosa at the time of endoscopy, selectively stains intestinilized mucosa (as opposed to normal or cancerous mucosa) blue. 2 The endoscopic appearance of our patient's gastric mucosa with intestinalization has, to our knowledge, not been reported. This appearance is reminiscent of a granular duodenum that is sometimes seen in patients with peptic ulcer disease. These patients had been treated with antacids, VOLUME 36, NO.5, 1990
Palliation of inoperable esophageal carcinoma now includes endoscopic laser ablation. Experience with the Nd:YAG laser in treating patients with these tumors has shown laser therapy to be both safe and effective.' We report the complication of pyogenic arthritis of the knee after Nd:YAG laser destruction of an obstructing esophageal cancer. A 69-year-old man was seen in May 1989 with a I-month history of dysphagia. Endoscopy and biopsy revealed an exophytic esophageal adenocarcinoma at 30 cm. Laparotomy with a view to resecting the tumor was abandoned because of the presence of metastatic deposits in celiac lymph nodes on frozen section. Palliation of the dysphagia was achieved by Nd:YAG laser therapy on three occasions (June 5, 12, and 26) with necrosis and destruction of the exophytic cancer. Esophageal dilation was not used, and the laser energy employed on each occasion was similar. Two weeks after the last laser treatment, the patient returned with a lO-day history of a swollen, painful left knee. There was no history of trauma, arthritis, or gout. On examination, the patient was febrile (38°C), with a swollen, red, hot, tender knee containing a large effusion. Radiology of the knee revealed gas within the large effusion. Under aseptic conditions, 200 ml of pus were aspirated from the knee, and the patient was started on gentamicin 545
