Routine EGD Research Articles

From Open-Type Atrophic Gastritis to Gastritis Staging

Dear Sir, We read with great interest the latest issue of Digestive Diseases and Sciences and, given our particular interests, we would like to briefly comment on three thoughtprovoking papers signed by Genta [1], Uedo [2] and, not last, by Ahn and coworkers [3]. Genta looks at the worldwide epidemiology of gastric cancer (GC) and correlates different socio-economic habits with GC risk. Addressing the etiological co-factors involved in gastric carcinogenesis, Genta notes that, ‘‘The relative influence of ... these factors on the rise and fall of GC is difficult to evaluate; since none is a sufficient cause of cancer, they must have acted synergistically’’ [1]. In this respect, without curbing the ‘‘leading’’ etiological role of H. pylori, we would like to mention that we recently documented a similar prevalence of both H. pylori and Cag-A status coexisting with impressive differences in the incidence of GC in different Siberian populations [4]. Our observation strongly supports the role of factors other than H. pylori in the etiology of ‘‘epidemic’’ GC. As Genta’s editorial suggests, such a constellation of non-Hp, environmental (?) factors should be further and more extensively addressed. Moving on to Uedo’s paper and its conclusive question, ‘‘... from the perspective of a practical endoscopist: do we need to take many biopsy specimens for assessing gastric cancer risk in... routine EGD?’’ [2], the answer is provided by the author a few lines further on: when both ‘‘gastric serology’’ (which is paid too little attention in non-Japanese clinical practice) and clinical examination consistently point to the need for an invasive diagnostic procedure (EGD), there can be no doubt that endoscopy and microscopy combined can identify patients warranting further diagnostic/therapeutic measures. Finally, Ahn and coworkers highlight the increased GC risk associated with the open phenotype of gastritis (i.e., multifocal atrophic gastritis, not restricted to the antrum) [3, 5]. The authors (who do not mention their biopsy sampling protocol) founded their conclusions on an elegant histological/immunohistochemical study, but it is worth noting that distinguishing between complete and incomplete intestinal metaplasia (IM) on the strength of H&E is only partially reliable (mucin histochemistry, i.e., high iron diamine [HID], is more appropriate). The clinical question, however, is whether we should perform (expensive and time-consuming) histochemistry and/or immunohistochemistry stains for a reliable assessment of the risk of GC. As in Ahn’s experience, when intestinalization of the gastric mucosa spreads from the antrum to the oxyntic M. Rugge (&) M. Fassan Department of Medical Diagnostic Sciences and Special Therapies, Surgical Pathology and Cytopathology Unit, University of Padua, Padua, Italy e-mail: massimo.rugge@unipd.it

Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study

The SEDASYS System is an investigational computer-assisted personalized sedation system integrating propofol delivery with patient monitoring to enable endoscopist/nurse teams to safely administer propofol. To compare the safety and effectiveness of the SEDASYS System to the current standard of care for sedation during routine endoscopic procedures. Nonblinded multicenter randomized comparative study. Four ambulatory surgery centers, 3 endoscopy centers, and 1 academic center in the United States. One thousand American Society of Anesthesiologists physical status class I to III adults undergoing routine colonoscopy or EGD. Sedation with the SEDASYS System (SED) and sedation with each site's current standard of care (CSC; benzodiazepine/opioid combination). Area under the curve of oxygen desaturation was the primary endpoint. Secondary endpoints included patient satisfaction, clinician satisfaction, level of sedation, and patient recovery time. Four hundred ninety-six patients were randomized to SED and 504 to CSC. Area under the curve of oxygen desaturation was significantly lower for SED (23.6 s·%) than for CSC (88.0 s·%; P = .028). Patients were predominately minimally to moderately sedated in both groups. SED patients were significantly more satisfied than CSC patients (P = .007). Clinician satisfaction was greater with SED than with CSC (P < .001). SED patients recovered faster than CSC patients (P < .001). The incidence of adverse events was 5.8% in the SED group and 8.7% in the CSC group. Nonblinded. The SEDASYS System could provide endoscopist/nurse teams a safe and effective on-label means to administer propofol to effect minimal to moderate sedation during routine colonoscopy and EGD.

During Routine EGD for GERD or Dyspepsia, Searching for HP Infection Increases by 7-Fold the Diagnostic Yield of Treatable Disease

Purpose: The purpose of our study was to compare the prevalence of HPI to the prevalence of SEMA in Pts referred for routine EGD for Dyspepsia or GERD and to determine how the diagnosis of each affected outcome. Methods: The complete records of consecutive first-time EGD exams performed for Dyspepsia or GERD from Jan 2005 through Dec 2008 were reviewed in detail by author A.M. Definitions: Outcomes: 1. Normal EGD - Symptoms had already stopped before EGD 2. Normal EGD - Symptoms continued after EGD 3. Normal EGD - Fate of symptoms uncertain 4. SEMA - endoscopic abnormalities that likely caused the GI symptoms and were likely to affect (positively or negatively) Pt outcome (e.g., cancer, ulcer, stricture, candidiasis, Barrett's). Results: 303 Pts (75 Dysp; 185 GERD) were referred for first-time EGD for symptoms. Of those with adequate data, EGD Dysp Outcome: 5/70 (7%) SEMA + EGD GERD Outcome: 27/233 (12%) SEMA + EGD Total Outcome: 32/303 (11%) SEMA + EGD Dysp Outcome: 14/67 = 21% HP-Pos: EGD GERD Outcome: 24/227 = 11% HP-Pos: EGD Total Outcome: 38/294 = 13% HP-Pos: Diagnostic findings that were likely to affect outcome were found: EGD observation alone (without Bx): xxx% of the 303 Pts. Bx alone for HPI: 13.9% of the 303 Pts. (Diff: 11.6%; 95% CI: 7.5%-17%; P: <0.0001). Overall, 13% of SEMA-Neg Pts will have HPI that will not be diagnosed. Endoscopic inspection alone diagnosed SEMA in 6% of all Pts, whereas the addition of routine Bx to search for HPI increased the diagnostic yield by 7-fold. Conclusion: In Pts already scheduled for EGD for Dysp or GERD, gastric Bx to diagnose HPI will increase by 7-fold the diagnostic yield of treatable disease and potentially prevent future serious outcomes.FigureFigure

Reply to Hu

It is important to know the frequency of epistaxis as one of the most common complications of ultrathin transnasal esophagogastroduodenoscopy (UT-EGD) to assess the safety of the procedure. Although there are a number of reports on epistaxis [1], the frequency of this complication largely varies. Such variance may result from lack of a grading standard of epistaxis occurring during UT-EGD. Particularly, as Dr. Hu mentions, the distinction between confined and unconfined hemorrhage is of great significance. Therefore, we have proposed to describe “confined” and “unconfined” hemorrhage as “oozing” and “overt” hemorrhage, respectively. We have encountered only a few cases in which oozing hemorrhage became overt bleeding, and most cases in which blood came out from the nostril and/or drained into the hypopharynx have been diagnosed as overt bleeding. Therefore, we believe that our grading is sufficient to establish the frequency and grade of epistaxis. Moreover, it would be stressful to patients to increase the session time in order to observe the nasal mucosa at the end of a routine EGD procedure. Of course, we agree that the recording of the “how” and “where” for nasomucosal injury is useful. According to our recent multicenter study (1862 patients enrolled), oozing (grade 2) and overt hemorrhage (grade 3) occurred in 7.8 % and 1.5 % of patients, respectively. The locations of bleeding were the middle turbinate (78 %), the inferior turbinate (15 %), and the nasal septum (6 %). We have never experienced bleeding at Kiesselbach’s plexus (Mori A. et al., unpublished observations).

Roux-en-Y loop varices in children with portal hypertension after liver transplantation: An unusual cause of “obscure” gastrointestinal bleeding

PHALT may result from graft dysfunction, portal vein thrombosis, arterio-venous fistulas and can lead to GIB, commonly from bleeding esophageal varices. We present three children with GIB requiring multiple blood transfusions that were diagnosed with RY Loop bleeding. Routine EGD, colonoscopy, and CE failed to reveal the bleeding source. However, enteroscopy revealed large varices at the site of hepaticojejunostomy anastomosis in all. Our experience demonstrates that RY loop varices in children with PHALT are a rare and treatable cause of obscure GI bleeding.

S1397: Efficacy and Safety of Endoscopic Mucosal Resection (EMR) of Duodenal Adenoma

Duodenal adenomas (DA) are diagnosed in surveillance programs of FAP and they can be infrequently detected as sporadic lesions during routine EGD. There are only few data on EMR of DA as a minimally invasive alternative to surgery.

Comprehensive imaging of gastroesophageal biopsy samples by spectrally encoded confocal microscopy

Spectrally encoded confocal microscopy (SECM) is a high-speed reflectance confocal microscopy technique that has the potential to be used for acquiring comprehensive images of the entire distal esophagus endoscopically with subcellular resolution. The goal of this study was to demonstrate large-area SECM in upper GI tissues and to determine whether the images contain microstructural information that is useful for pathologic diagnosis. A feasibility study. Gastrointestinal Unit, Massachusetts General Hospital. Fifty biopsy samples from 36 patients undergoing routine EGD were imaged by SECM, in their entirety, immediately after their removal. The microstructure seen in the SECM images was similar to that seen by histopathology. Gastric cardia mucosa was clearly differentiated from squamous mucosa. Gastric fundic/body type mucosa showed more tightly packed glands than gastric cardia mucosa. Fundic gland polyps showed cystically dilated glands lined with cuboidal epithelium. The presence of intraepithelial eosinophils was detected with the cells demonstrating a characteristic bilobed nucleus. Specialized intestinal metaplasia was identified by columnar epithelium and the presence of goblet cells. Barrett's esophagus (BE) with dysplasia was differentiated from specialized intestinal metaplasia by the loss of nuclear polarity and disorganized glandular architecture. Ex vivo, descriptive study. Large-area SECM images of gastroesophageal biopsy samples enabled the visualization of both subcellular and architectural features of various upper GI mucosal types and were similar to the corresponding histopathologic slides. These results suggest that the development of an endoscopic SECM probe is merited.

Hypoxemia Risk Factors During Sedation in ASA I/II Populations for Midazolam- and Propofol-Mediated Sedation for Routine EGD and Colonoscopy

Purpose: Hypoxemia is the most common cardiopulmonary event during endoscopic sedation. The risk factors for hypoxemia in a healthy ASA I/II patients have not been extensively studied in a large population. Methods: A post hoc analysis from a multicenter randomized controlled trial of subjects undergoing routine colonoscopy or EGD was performed. 1000 ASA I/II/III subjects with a BMI < 35 were randomized to receive either midazolam or propofol-mediated sedation by an endoscopist/nurse team. 494 ASA I/II subjects (357 colon, 137 EGD) received midazolam-mediated sedation. 478 subjects ASA I/II (347 colon, 131 EGD) received propofol-mediated sedation using the SEDASYS® System, an investigational device. Both groups also received a narcotic (fentanyl for propofol-mediated; fentanyl or meperidine for midazolam-mediated). The sedation target for both groups was minimal to moderate sedation. Pulse oximetry, capnography, BP and ECG data points were captured for both groups every second using a computerized digital storage device. Hypoxemia was defined as an O2 saturation <90% for >15 seconds. Potential risk factors analyzed were age ≥ 55 years, gender, BMI ≥ 30, BMI ≤ 20, and a history of cardiovascular or neurological/psychiatric disorders. The factors were analyzed using a multivariate ANOVA. Results: The number of subjects with hypoxemic events was significantly higher (p < 0.001) in the midazolam-mediated arm (76 subjects, 170 events) than in the propofol-mediated arm (32 subjects, 42 events). The risk factors for hypoxemia for the midazolam-mediated group that had statistical significance were subjects with a BMI ≥ 30 or a previous history of cardiovascular disease (Table 1). The propofol-mediated group showed no statistically significant risk factors (p > 0.15 for all factors), though the most influential risk factors mirrored those of the midazolam group, BMI ≥ 30 or a previous history of cardiovascular disease. Also of note, for the midazolam group gender as a risk factor (p=0.067) almost had statistical significance. There were 49% (243/494) females in the midazolam group. In the midazolam group 61% (46/76) of the subjects who experienced hypoxemia were female (49%). For the subjects who experienced hypoxemia the gender breakdown for the midazolam group showed a bias for hypoxemia for females.Table 1: Hypoxemia risk factors for Midazolam and propofol groupsConclusion: Even healthy subjects as defined by ASA I/II are prone to hypoxemia during endoscopic sedation. Propofol-mediated sedation using the SEDASYS System resulted in a significantly lower incidence of hypoxemia and appeared to mitigate the risk factors associated with midazolam-mediated sedation. Disclosure: John J. Vargo, MD, MPH, FACG, Consultant,Ethicon Endo-Surgery, Cininnati, OH Daniel J. Pambianco, MD, FACG Consultant,Ethicon Endo-Surgery, Cininnati, OH Paul Niklewski, BS Employee, Ethicon Endo-Surgery, Cininnati, OH.

Sedation during endoscopy for patients at risk of obstructive sleep apnea

Obstructive sleep apnea (OSA) has become increasingly prevalent in the United States and often goes undiagnosed. To assess the proportion of patients undergoing routine endoscopic procedures who are at risk of OSA and to determine whether these patients are at risk of sedation-related hypoxia. Prospective case-control study at an academic medical center. Patients undergoing routine EGD and colonoscopy were administered the Berlin Questionnaire, a brief validated survey that stratifies patients into high or low risk of OSA. Data on pulse oximetry and oxygen use were collected. Rates of transient hypoxia, defined as a pulse oximetry measurement less than 92% requiring an increase in supplemental oxygen were compared between the high- and low-risk OSA groups. Of the 261 prospectively recruited patients, 28 were excluded for violating study protocol. Ninety (39%) of the remaining 233 patients were scored as being at high risk of OSA. There was no significant difference in the rate of transient hypoxia between the high- and low-risk groups (odds ratio 1.48; 95% CI, 0.58-3.80). Single-center study. OSA was not confirmed with a sleep study. Approximately one third of patients undergoing routine outpatient endoscopic procedures at a university hospital scored as being at high risk of OSA. There was no significant difference in the rates of transient hypoxia between high- and low-risk groups, suggesting that the majority of patients with no diagnosis of OSA can undergo conscious sedation for routine endoscopic procedures with standard monitoring practices.

Respiratory Hazards of Esophagogastroduodenoscopy (EGD) in the Setting of a Giant Diaphragmatic Hernia

Purpose: Large transdiaphragmatic hernias more often are seen as a consequence of trauma (penetrating, blunt or post-surgical) than of progressive enlargment of hiatal hernias. Given widespread availability of EGD, diaphragmatic hernias of various sizes are frequently identified. We present a patient with a massive left-sided diaphragmatic hernia who experienced unique complications related to performance of EGD. Methods: A 62 year old woman presented in 2006 with UGI bleeding. An EGD utilizing IV conscious sedation was completed uneventfully and without complications; findings included a gastric ulcer and a large hiatal hernia, despite the patient having undergone a fundoplication in 1977. Review of her medical records revealed a CT scan done from 2004 that revealed a large left-sided diaphragmatic hernia containing stomach, spleen, mesenteric fat and a portion of the transverse colon. She had been previously referred to a thoracic surgeon but told she was “too high risk” for surgical repair of the diaphragmatic hernia. She was lost to follow-up until 2008 when a repeat CT scan showed the pancreatic tail and portions of the jejunum, descending and transverse colon in the hernia, as well as the stomach and spleen. Also described was compressive atelectasis of the left lung secondary to the herniated abdominal viscera. The patient was again referred for surgical evaluation and repeat EGD was recommended as part of her pre-operative workup. Immediately prior to EGD while the patient was in the left lateral decubitus position, it was noted on pulse oximetry that her 02 saturation fluctuated between 60–90%. These readings were considered spurious, since she was completely awake and alert. EGD was subsequently performed utilizing IV conscious sedation; pulse oximetry values ranged between 60–80% during the less than 10 minute procedure. Afterward, the patient remained hypoxemic and lethargic. She then began complaining of dyspnea and appeared confused and disoriented, so IV naloxone and flumazemil were administered. Over the next 15–20 minutes her disorientation and dyspnea slowly abated, with improvement in her O2 saturation to 80–90%. Results: The patient's respiratory decompensation after EGD was attributed to respiratory depression secondary to IV conscious sedation superimposed on the marked loss of left lung function resulting from the compressive effects of abdominal organs and exacerbated by both the left lateral decubitus position and air insufflation of the stomach. Conclusion: Routine EGD, and probably colonoscopy as well, should be performed with caution in patients with giant diaphragmatic hernias (especially those containing abdominal viscera besides the stomach) because of the significant risk of respiratory complications.

Upper Endoscopy in Patients with Acute Myocardial Infarction and Upper Gastrointestinal Bleeding: Results of a Decision Analysis

The management of patients with acute myocardial infarction (AMI) and upper gastrointestinal bleeding (UGIB) can present a challenge. The utility of upper endoscopy (esophagogastroduodenoscopy, EGD) and endoscopic therapy must be weighed against safety considerations. To assess the utility and safety of EGD in patients with UGIB and AMI. Using decision analysis, patients with UGIB and AMI were assigned to one of two strategies: (1) EGD prior to cardiac catheterization (EGD strategy) and (2) cardiac catheterization without EGD (CATH strategy). In patients with overt UGIB, the EGD strategy resulted in 97 deaths per 10,000 patients, compared with 600 deaths in the CATH strategy. The EGD strategy resulted in fewer non-fatal complications (1,271 vs. 6,000 per 10,000 patients). In patients with occult blood loss, the EGD strategy resulted in more deaths (59 vs. 16 per 10,000) and more non-fatal complications (888 vs. 160 per 10,000) than the CATH strategy. Our analysis supports EGD prior to cardiac catheterization in patients with AMI and overt UGIB. This strategy results in fewer deaths and complications compared with a strategy of proceeding directly to catheterization. Our analysis does not support routine EGD prior to cardiac catheterization in patients with fecal occult blood.

Unique Endoscopic Futures of Corpus Gastritis with H. Pylori Infection in Children and Adolescents; Close Observation By Conventional Endoscopy and Magnified Endoscopy

Backgrounds: Antral nodularity is the only reliable endoscopic feature in H. pylori (Hp) infected children. We reported that the regular arrangement of collecting venules (RAC) visible as numerous minute points by close observation of the gastric corpus with conventional endoscopy was indicative of Hp-negative normal stomachs. Aims: To evaluate the endoscopic futures of corpus gastritis with Hp infection in children and adolescents. Methods: From January 2001 to March 2005, 87 consecutive children and adolescents underwent EGD for UGI symptoms or anemia (38 boys, median age 13 y, range 9∼15 years). Hp positive was defined as both positive of 13C-UBT and histology. EGD was performed using a standard small caliber endoscope (GIF-XP 240 or 260; Olympus) and biopsy specimens were taken from the antrum, lower corpus lesser curvature, and upper corpus greater curvature for histopathology. After the routine EGD, close observation was performed at the point of lower corpus lesser curvature and upper corpus greater curvature (near biopsy sites). Each case was scored as RAC positive if the minute points were irregularly present or if absent, as RAC negative. In 8 patients (4 Hp negative and 4 positive) EGD was performed using magnifying endoscopy (GIF-Q240Z; Olympus) and the magnified view was compared to RAC pattern. Results: Of the 87 patients, 25 (29%) were Hp positive. By routine endoscopy, 7 patients were diagnosed as DU with Hp infection; 21 had antral nodularity with Hp gastritis. The RAC-negative pattern was observed in 27 patients and 21 (78%) were Hp positive. In the upper corpus greater curvature RAC was negative in 30 patients and 25 (83%) were Hp positive. The sensitivity, specificity, and accuracy of RAC-negative were 100%, 87%, and 91% in the lower corpus lesser curvature and 100%, 91%, and 94% in the upper corpus lesser curvature. In Hp negative and RAC-positive patients, magnifying endoscopy showed true capillaries forming around collecting venules in the gastric corpus. In Hp positive and RAC-negative patients, collecting venules and true capillaries were not seen and gastric pits and sulci were observed. Conclusion: The RAC negative pattern as identified by close observation of the gastric corpus using conventional endoscopy uniquely reflects corpus gastritis with Hp infection in children and adolescents.

Endoscopy Plays an Important Preoperative Role in Bariatric Surgery

The role of upper endoscopy (EGD) in obese patients prior to bariatric surgery is controversial. The aim of this study was to evaluate the diagnostic yield and cost of routine EGD before bariatric surgery. The medical records of consecutive obese patients who underwent EGD prior to bariatric surgery between May 2000 and September 2002 were reviewed. Two experienced endoscopists reviewed all EGD reports, and findings were divided into 4 groups based on predetermined criteria: group 0 (normal study), group 1 (abnormal findings that neither changed the surgical approach nor postponed surgery), group 2 (abnormal findings that changed the surgical approach or postponed surgery), and group 3 (results that were an absolute contraindication to surgery). Clinically important findings included lesions in groups 2 and 3. The cost of EGD (430.72 US dollars) was estimated using the endoscopist fee under Medicare reimbursement. During the 28-month study period, 195 patients were evaluated by EGD prior to bariatric surgery. One or more lesions were identified in 89.7% of patients, with 61.5% having a clinically important finding. The prevalence of endoscopic findings using the classification system above was as follows: group 0 (10.3%), group 1 (28.2%), group 2 (61.5%), and group 3 (0.0%). Overall, the most common lesions identified were hiatal hernia (40.0%), gastritis (28.7%), esophagitis (9.2%), gastric ulcer (3.6%), Barrett's esophagus (3.1%), and esophageal ulcer (3.1%). The cost of performing routine endoscopy on all patients prior to bariatric surgery was 699.92 US dollars per clinically important lesion detected. Routine upper endoscopy before bariatric surgery has a high diagnostic yield and has a low cost per clinically important lesion detected.

Silent peptic ulcer disease: frequency, factors leading to “silence,” and implications regarding the pathogenesis of visceral symptoms

Background Peptic ulcer disease may occur in the absence of dyspeptic symptoms. The pathogenesis of dyspepsia in peptic ulcer disease is unclear. Whether the presence of Helicobacter pylori infection or use of non-steroidal anti-inflammatory drugs affects dyspeptic symptoms in patients with peptic ulcer disease has not been determined. The aim of the study was to determine the frequency and risk factors for peptic ulcer disease in a cohort of asymptomatic, unselected patients undergoing routine screening EGD. Methods This was a prospective study of a cohort of Chinese subjects undergoing screening EGD as part of a routine health maintenance program. Routine EGD screening was performed in 6457 consecutive subjects who underwent a self-paid, health evaluation. Those with endoscopy-confirmed peptic ulcer disease were enrolled to assess the risk factors that distinguish asymptomatic patients with peptic ulcer disease from patients with symptoms because of peptic ulcer disease. Results A total of 704 (10.9%) patients were found to have peptic ulcer disease, of which two thirds (n = 496) were asymptomatic. Both uni- and multivariate analysis showed that the asymptomatic patients tended to have a larger body mass index, to be habitual tea drinkers, and to have an ulcer that was less than 1 cm in diameter and in a healing stage. Gender, blood group, history of hypertension and/or diabetes, ulcer location, Helicobacter pylori status, use of non-steroidal anti-inflammatories or sedative medications, habitual coffee drinking, and habits with respect to smoking of tobacco or ingestion of alcohol, had no association with symptoms. Conclusions The results of this study suggest that silent peptic ulcer disease is common in Taiwan. Dyspeptic symptoms because of peptic ulcer disease may be influenced by intrinsic (body mass index and ulcer characters) and extrinsic (habitual tea drinking) factors. Non-steroidal anti-inflammatory drug use and Helicobacter pylori status had no significant effect on the symptomatology of peptic ulcer disease. These findings may contribute to the understanding of the pathogenesis in the visceral symptoms of peptic ulcer disease.

Routine preop EGD for gastric bypass: Are clinical features predictive of findings?

Routine preop EGD for gastric bypass: Are clinical features predictive of findings?

3404 Assessing visual quality and coverage of routine diagnostic esophagogastroduodenoscopy (egd): use of a systematic review model.

Introduction: Assessing and maintaining the quality of endoscopic examinations is important for endoscopic training and continuing education. A single small study has previously assessed the quality of colonoscopic examinations. However, there are few data on structured systems for assessing visual quality and coverage of EGD. Aim: To develop and evaluate a comprehensive model for assessing the quality of routine diagnostic EGD. Methods: 27 consecutive routine EGD s performed by an experienced endoscopist using an Olympus GIF XQ230 were videotaped for analysis. Clinical and endoscopic details were recorded, and the endoscopist scored visual quality in a systematic manner by dividing the upper gastrointestinal tract into 24 discrete sections (esophagus (n=4), stomach (n=12), duodenum (n=8)). Visual quality in each section was scored from 0-3 (0, no view-no attempt to visualise mucosa; 1, inadequate-might fail to detect ulcer; 2, adequate-might miss scattered erosions but would detect a small ulcer; 4, excellent, would detect scattered erosions). An experienced endoscopist, who was blinded to clinical details and results, reviewed each videotape using the same scoring system. The reviewer also commented on abnormalities seen during video review. Results: Overall, 634 individual upper GI segments were analyzed in 27 patients (median age 62 years, range 24-87; 15 female). 14 segments were not present in a single patient due to previous gastroenterostomy. The endoscopist scored 2 sections 0, 12 sections 1, 221 sections 2 and 399 sections 3. The reviewer scored 4 sections 0, 96 sections 1, 253 sections 2 and 281 sections 3. Overall, the agreement between endoscopist and reviewer was moderate (kappa statistic 0.41, p

7129 Dual contrast spraying endoscopy in patients with barrett`s esophagus. a seven year follow-up with nice results.

34 patients with histologically proven Barrett`s esophagus (BE)were followed since 1994 using a combined technique to direct in search of zones of dysplasia. In every patient with BE I used a combined technique to enhance contrast between gastric and esophageal mucosa based in the physiology of the lining epithelia to directly take of the biopsies. The technique is under a routine EGD endoscopy first it was sprayed the acetic acid at the squamo-columnar junction in short spurs to cover the suspicious areas and then after it was sprayed the 2.5% Lugol`s solution over the esophageal mucosa in the same manner to make the real enhanced contrast. Acetic acid enhances the pattern of the metaplastic epithelia making the area of suspicious dysplasia look like a white towel, causing an excellent contrast. The pathologist graded the findings with the inflammatory criteria and the presence of low (LGD)or high grade dysplasia (HGD), besides another histopathological findings such as presence of virus. All patients had medical treatment based in a 20 mg Pantoprazole O.D. or Rabeprazole 20 mg O.D. and reinforced behavior-diet-higienical anti-reflux measures . The follow up was each year if no inflammation or no dysplasia but symptoms were seen, each 12 months if there was LGD no matter the grade of inflammation and every six months if there was LGD with a strong degree of inflammation. Special care was taken when HGD was found with a very close endoscopic surveillance and high dose of PPI`s. Among the 34 patients that I followed 28/34 patients have had antireflux surgery, 18/34 had a LGD with no progression, and 3/34 HGD, in their follow up 2/34 of the HGD were found to have a adenocarcinoma in-situ that make the must to have esophagectomy. In conclusion the dual contrast spraying of the esophagus in patients with the BE reinforces the lugol`s staining or the random 4 quadrant each 2 cm biopsies making the columnar mucosa to contrast as aceto-white lining and is useful to help to find premalignant lesions or stages, remembering that from the metaplastic mucosa is where very often arises the adenocarcinoma. Future techniques as thermo-ablation or special wave-lenght-light will resolve definitely the worry of the 10% probability to get a cancer when BE is found. This is a simple physiological-based contrast to help any standard procedure to improve the diagnostic accuracy.

Pharmacoeconomic evaluation of flumazenil for routine outpatient EGD

Background: Flumazenil is a benzodiazepine antagonist indicated for reversal of the sedative effects of benzodiazepines. Previous studies suggest that flumazenil may shorten recovery time after endoscopy, but there are few data on actual recovery room times and charges. Methods: Fifty patients undergoing routine upper endoscopy were sedated with midazolam alone in the usual titrated manner. Patients were randomized in a double-blind fashion to receive either flumazenil or saline immediately after procedure. Assessments of responsiveness, speech, facial expression, and ptosis (Observer's Assessment of Alertness/Sedation [OAA/S] scale) were made before procedure, immediately after procedure and every 15 minutes thereafter. The patient was discharged from the recovery room when vital signs and OAA/S scale reached preprocedure levels. Recovery room times and charges were recorded. Results: The flumazenil group demonstrated shorter recovery room times and recovery room charges than the placebo group ( p < 0.001). The difference in recovery room charges was not statistically different when flumazenil charges were included ( p = 0.09). Conclusions: The routine use of flumazenil after midazolam sedation for upper endoscopy significantly shortened recovery time and charges but did not statistically reduce overall charges. (Gastrointest Endosc 2000;51:282-7.)