Atropine for colonoscopy: no benefit
procedure, causing parotid vasodilation and consequent transient enlargement. 2
To the Editor: Dr. Waxman and colleagues, in their study demonstrating no significant benefit from atropine for colonoscopy,! mention "there have been no prospectively designed trials to evaluate the usefulness of atropine during colonoscopy." They have overlooked a study by Ms. Saviage and myself, probably because it was published as an abstract. 2 We prospectively studied 108 patients undergoing colonoscopy. They were randomized to receive 1 mg of atropine subcutaneously or an identical-appearing injection of saline 5 min before the procedure. The patients and the endoscopist were blinded. Each patient received 0.07 mg of diazepam/kg intravenously for the procedure (not "0.07 mg" as indicated in the abstract-a typographical error). We evaluated the ease of colonoscopy from both the patient's and endoscopist's viewpoint and colonic motility and, like Dr. Waxman et al., demonstrated no significant benefit from pre-medication with atropine. We found no cardiac complications in either group.
Sandeep Nijhawan, MD R. R. Rai, MD Department of Gasuoenterology SMS Medical College Jaipur, India
REFERENCES 1. Blackford RW. Recurrent swelling of parotid and submaxillary gland following bronchoscopy. Ann Otol Rhinol Laryngol 1974;53:54-64. 2. Bonchek LI. Salivary gland enlargement during induction of anaesthesia. JAMA 1969;209:1716-8. 3. Slaughter RL, Boyce HW. Submaxillary gland swelling developing during peroral endoscopy. Gastroenterology 1969;57:838. 4. Shields HM, Soloway RD, Long WB, Weiss JB. Bilateral recurrent parotid swelling after endoscopy. Gastroenterology 1977;73:164-5. 5. Gardon MJ. Transient submandibular swelling following esophagoduodenoscopy. Am J Dig Dis 1976;21:507-8. 6. Slaughter RL. Parotid gland swelling developing during peroral endoscopy. Gastointest Endosc 1975;22:38-9.
Robert G. Norfleet, MD Kay Saviage, LPN Department of Gastroenterology Marshfield Clinic Marshfield, Wisconsin
Gastric syphilis: an unusual endoscopic appearance To the Editor:
REFERENCES 1. Waxman I, Mathews J, Gallagher J, et al. Limited benefit of atropine as pre-medication for colonoscopy. Gastrointest Endose 1991;37:329-31. 2. Norfleet RG, Saviage K: Atropine premedication for colonoscopy: a randomized double-blind study [Abstract]. Gastrointest Endosc. 1983;29:157.
Parotid swelling after upper gastrointestinal endoscopy To the Editor: We report a rare complication after upper gastrointestinal endoscopy. A 40-year-old woman underwent the procedure for suspected non-ulcer dyspepsia. The procedure was completed in 5 min although the patient strained and coughed during the initial part of the procedure. No medication was given to the patient before the procedure, and there was no past history of parotid swelling. Immediately after the procedure, the patient developed painful swelling of the right parotid gland, which was tender on palpation. The swelling subsided in 3 hours without specific medication. Such complications have been reported in the past following bronchoscopy,! endotracheal intubation for anesthesia,2 rigid esophagoscopy,3 and flexible upper gastrointestinal endoscopy.4 Submandibular5 and parotid4,6 salivary glands are involved. There are three proposed mechanisms. First, it may be because of retention of saliva resulting from blocking of ducts by thick secretions. 4 Second, coughing and straining during the procedure may lead to venous congestion of the parotid gland. Finally, swelling may arise as a result of intense parasympathetic stimulation during the 94
Dating back to the great pox pandemic of the late 15th century, syphilis has been recognized as an entity with protean manifestations. Although gastrointestinal manifestations may range from patchy proctitis to lesions resembling malignancy, the stomach is the most commonly involved site in gastrointestinal syphilis. 1 Beginning with the introduction of penicillin, the incidence of syphilis and reports of gastric involvement declined markedly. In the last 20 years, there have been only eight reports of biopsy-proven gastric syphilis in the English literature. 2-9 In the last decade, however, the number of reported cases of syphilis has risen steadily.lO We report a case of gastric syphilis characterized by an unusual endoscopic appearance. A previously healthy 26-year-old man was admitted to the hospital because of epigastric pain, nausea, and coffeeground emesis beginning 1 week before admission. The physical examination revealed no mucous membrane lesions in the oropharynx or urogenital area. There was no adenopathy. Abdominal examination showed only moderate epigastric tenderness, and the rectal examination was normal with heme-negative stool. Routine laboratory tests were normal, and his hematocrit was 44%. Esophagogastroduodenoscopy revealed a normally distensible stomach with a normal-appearing esophagus and duodenum. The stomach itself, however, contained more than 100 shallow ulcerations, ranging in size from a few millimeters to 1 em, which were concentrated most heavily in the antrum. They were notable for their brownish purplecolored bases and whitish exudate along their border (Fig. 1). There was no evidence of focal hemorrhage, and the intervening mucosa appeared to be normal. In addition, a solitary, deep, 5-cm ulcer was seen along the angulus. Biop~SrnillN~STI~LEND~C~Y
procedure, causing parotid vasodilation and consequent transient enlargement. 2
To the Editor: Dr. Waxman and colleagues, in their study demonstrating no significant benefit from atropine for colonoscopy,! mention "there have been no prospectively designed trials to evaluate the usefulness of atropine during colonoscopy." They have overlooked a study by Ms. Saviage and myself, probably because it was published as an abstract. 2 We prospectively studied 108 patients undergoing colonoscopy. They were randomized to receive 1 mg of atropine subcutaneously or an identical-appearing injection of saline 5 min before the procedure. The patients and the endoscopist were blinded. Each patient received 0.07 mg of diazepam/kg intravenously for the procedure (not "0.07 mg" as indicated in the abstract-a typographical error). We evaluated the ease of colonoscopy from both the patient's and endoscopist's viewpoint and colonic motility and, like Dr. Waxman et al., demonstrated no significant benefit from pre-medication with atropine. We found no cardiac complications in either group.
Sandeep Nijhawan, MD R. R. Rai, MD Department of Gasuoenterology SMS Medical College Jaipur, India
REFERENCES 1. Blackford RW. Recurrent swelling of parotid and submaxillary gland following bronchoscopy. Ann Otol Rhinol Laryngol 1974;53:54-64. 2. Bonchek LI. Salivary gland enlargement during induction of anaesthesia. JAMA 1969;209:1716-8. 3. Slaughter RL, Boyce HW. Submaxillary gland swelling developing during peroral endoscopy. Gastroenterology 1969;57:838. 4. Shields HM, Soloway RD, Long WB, Weiss JB. Bilateral recurrent parotid swelling after endoscopy. Gastroenterology 1977;73:164-5. 5. Gardon MJ. Transient submandibular swelling following esophagoduodenoscopy. Am J Dig Dis 1976;21:507-8. 6. Slaughter RL. Parotid gland swelling developing during peroral endoscopy. Gastointest Endosc 1975;22:38-9.
Robert G. Norfleet, MD Kay Saviage, LPN Department of Gastroenterology Marshfield Clinic Marshfield, Wisconsin
Gastric syphilis: an unusual endoscopic appearance To the Editor:
REFERENCES 1. Waxman I, Mathews J, Gallagher J, et al. Limited benefit of atropine as pre-medication for colonoscopy. Gastrointest Endose 1991;37:329-31. 2. Norfleet RG, Saviage K: Atropine premedication for colonoscopy: a randomized double-blind study [Abstract]. Gastrointest Endosc. 1983;29:157.
Parotid swelling after upper gastrointestinal endoscopy To the Editor: We report a rare complication after upper gastrointestinal endoscopy. A 40-year-old woman underwent the procedure for suspected non-ulcer dyspepsia. The procedure was completed in 5 min although the patient strained and coughed during the initial part of the procedure. No medication was given to the patient before the procedure, and there was no past history of parotid swelling. Immediately after the procedure, the patient developed painful swelling of the right parotid gland, which was tender on palpation. The swelling subsided in 3 hours without specific medication. Such complications have been reported in the past following bronchoscopy,! endotracheal intubation for anesthesia,2 rigid esophagoscopy,3 and flexible upper gastrointestinal endoscopy.4 Submandibular5 and parotid4,6 salivary glands are involved. There are three proposed mechanisms. First, it may be because of retention of saliva resulting from blocking of ducts by thick secretions. 4 Second, coughing and straining during the procedure may lead to venous congestion of the parotid gland. Finally, swelling may arise as a result of intense parasympathetic stimulation during the 94
Dating back to the great pox pandemic of the late 15th century, syphilis has been recognized as an entity with protean manifestations. Although gastrointestinal manifestations may range from patchy proctitis to lesions resembling malignancy, the stomach is the most commonly involved site in gastrointestinal syphilis. 1 Beginning with the introduction of penicillin, the incidence of syphilis and reports of gastric involvement declined markedly. In the last 20 years, there have been only eight reports of biopsy-proven gastric syphilis in the English literature. 2-9 In the last decade, however, the number of reported cases of syphilis has risen steadily.lO We report a case of gastric syphilis characterized by an unusual endoscopic appearance. A previously healthy 26-year-old man was admitted to the hospital because of epigastric pain, nausea, and coffeeground emesis beginning 1 week before admission. The physical examination revealed no mucous membrane lesions in the oropharynx or urogenital area. There was no adenopathy. Abdominal examination showed only moderate epigastric tenderness, and the rectal examination was normal with heme-negative stool. Routine laboratory tests were normal, and his hematocrit was 44%. Esophagogastroduodenoscopy revealed a normally distensible stomach with a normal-appearing esophagus and duodenum. The stomach itself, however, contained more than 100 shallow ulcerations, ranging in size from a few millimeters to 1 em, which were concentrated most heavily in the antrum. They were notable for their brownish purplecolored bases and whitish exudate along their border (Fig. 1). There was no evidence of focal hemorrhage, and the intervening mucosa appeared to be normal. In addition, a solitary, deep, 5-cm ulcer was seen along the angulus. Biop~SrnillN~STI~LEND~C~Y
