A dark-pigmented (black) esophagus is a rare observation during the course of upper endoscopy. The differential diagnosis of a black esophagus includes acute necrotizing esophagitis, exogenous dye ingestion, lye ingestion, malignant melanoma, melanosis, and pseudomelanosis esophagi. Many of these conditions are suggested by the history and associated endoscopic findings. In most patients, a biopsy is needed to establish a definitive diagnosis and explanation for the black-appearing esophagus. We describe a patient with a black esophagus encountered during routine endoscopy. The clinical, endoscopic, and histopathological features of this unusual finding are presented, along with a review of the literature.
The American College of Gastroenterology (ACG) Institute for Clinical Research and Education conducted a survey study to assess demographics, management strategies, and outcome for patients with gastrointestinal bleeding. This pilot project was intended to determine the feasibility of surveying the ACG membership about common clinical issues.Color-coded survey forms were sent to all ACG members and Fellows, with instructions to supply information about demographics, presenting symptoms, management, and outcome for bleeding patients and procedure-matched controls. Forms returned between June 1 and August 31, 1995, were tabulated and analyzed for differences between the bleeding group and procedure-matched controls.A total of 1235 forms were returned by respondents, 60% of whom were in private practice. Patient demographics indicated that bleeding patients were significantly older, more likely to be male, and more likely to use alcohol, tobacco, and prescription or over-the-counter aspirin or nonsteroidal anti-inflammatory drugs and anticoagulants than were controls. Upper GI bleeding accounted for 76% of bleeding events, with duodenal and gastric ulcers being the source in more than 50% of the upper GI bleeders. Diverticula was the most common bleeding source identified in lower GI bleeders. In the bleeding group, 78.8% were anemic, with 60.9% having hemoglobin of <10 g/dl; 31% presented with orthostatic changes in blood pressure or shock. Most bleeding subjects, regardless of source, were hospitalized, 58.2% received blood transfusions, and 45.5% received endoscopic therapy. Rebleeding (11.2%), need for surgery (7.1%), and fatalities (2.1%) were uncommon. Over-the-counter aspirin and nonsteroidal anti-inflammatory drugs were used significantly more often in the bleeding population (47.6%) than in controls (19.4%).The success of the GI Bleeding Registry supports the feasibility of surveying ACG members about common clinical problems. Data suggest that ACG members manage sick patients with severe gastrointestinal bleeding who require hospitalization, transfusions, and endoscopic treatment. These preliminary results will serve as an impetus to conduct further survey studies of gastrointestinal bleeding and other common digestive disease conditions.
Existing animal models of ulcerative bleeding are not suitable for endoscopic investigation. We describe a new porcine model of massive arterial bleeding in the stomach and its use for assessing a novel endoscopic suturing device.Two animal models were investigated. In model 1, the short gastric artery (mean diameter 2 mm) was divided near its gastric end. A mucosal defect was created near the greater curve and the divided artery was brought into the lumen of the stomach through a submucosal tunnel. An inflatable plastic cuff was placed around the base of the artery. Cuff deflation led to massive bleeding. In model 2, the short gastric artery was carefully exposed along a segment of 2 cm on the side facing the stomach. It was then anchored to a small gastrostomy made at the posterior wall near the vessel. At endoscopy an ulcer-like lesion could be seen with a pulsatile vessel at the base and brisk bleeding could be started by cutting a hole in the artery using endoscissors. The pigs were heparinized by an intravenous bolus of 110-300 units per kilogram, in both models. A prototype suturing device, the Eagle Claw, was inserted using a gastroscope and the curved needle was driven around the bleeding artery. Extracorporeal knotting or intracorporeal ligation was done endoscopically.Pulsatile arterial bleeding was successfully created in four pigs using model 1, and in another four pigs using model 2. Model 2 was more reproducible and less time-consuming to create. Endoscopic suturing controlled arterial bleeding in five out of eight pigs with a single stitch and in another three pigs with an additional stitch.This animal model provides reproducible massive hemorrhage suitable for endoscopic studies. Control of gastric bleeding from large arteries by endoscopic suturing is possible.
The elderly patient with acute gastrointestinal bleeding requires a management approach that attends to age-dependent demands, such as functional status, the independent impact of functional status on outcomes such as short term mortality, and the consent process. This review examines issues such as patient triage, resuscitation, diet and medications, anticoagulation, endoscopy and conscious sedation, informed consent in the impaired patient, and discharge planning in light of these age-dependent demands.
Radiation proctopathy can be a disabling delayed outcome of radiation therapy directed at pelvic malignancies. Rectal outlet bleeding can be severe enough to result in anemia and transfusion dependency. Bleeding typically develops from 6 months to 1 year after completion of radiation therapy and is caused by friable mucosal angioectasias. Although many approaches to controlling bleeding from chronic radiation proctopathy have been attempted, ranging from topical enema formulations to surgical diversion of the rectum, endoscopic coagulation therapy remains the most effective. This review provides the background issues surrounding the development of chronic bleeding radiation proctopathy and focuses on endoscopic methods of treatment.
Periampullary adenomas are an increasingly recognized condition, both in those with familial adenomatous polyposis syndromes (FAP) as well as sporadic cases. Endoscopic management has been advocated for these lesions without differentiating between these two patient groups regarding aim of therapy. The aims of this study were to determine the safety and effectiveness of endoscopic surveillance and ablative therapy of periampullary adenomas in patients with both sporadic and FAP-associated lesions.Retrospective analysis of 59 patients with FAP and 32 with sporadic lesions who were all enrolled in a program of endoscopic surveillance and ablative therapy. Median follow-up was 24 months (range, 1-134 months).Ampullary ablative therapy has resulted in return to normal histology in 44 and 34% of sporadic and FAPassociated lesions, respectively. Complications of endoscopic therapy were mild in 12 patients and severe in 3 patients: the latter category involved one occurrence of asymptomatic duodenal stenosis and one occurrence of postcoagulation syndrome--both after Nd-YAG laser therapy-and necrotizing pancreatitis after ampullary biopsy in one patient. Thirteen patients have been referred for surgical intervention. There has been no mortality and no cases of advanced malignancy missed by endoscopy.Endoscopic surveillance and ablative therapy of periampullary lesions is safe and can be effective, although eradication of ampullary tissue requires multiple ablative sessions.
Reliable closure of the transluminal incision is the crucial step for natural orifice transluminal endoscopic surgery (NOTES) procedures. The aim of this study was to evaluate the feasibility and effectiveness of transgastric access closure with a flexible stapling device in a porcine survival model.We carried out four experiments (two sterile and two nonsterile) on 50 kg pigs. The endoscope was passed through a gastrotomy made with a needle knife and an 18-mm controlled radial expansion dilating balloon. After peritoneoscopy, a flexible linear stapling device (NOLC60, Power Medical Interventions, Langhorne, Pennsylvania, USA) was perorally advanced over a guide wire into the stomach, positioned under endoscopic guidance, and opened to include the site of gastrotomy between its two arms; four rows of staples were fired. One animal was sacrificed 24 hours after the procedure (progression of pre-existing pneumonia). The remaining animals were survived for 1 week and then underwent repeat endoscopy and postmortem examination.Peroral delivery and positioning of the stapling device involved some technical difficulties, mostly due to the short length (60 cm) of the stapling device. The stapler provided complete leak-resistant gastric closure in all pigs. None of the surviving animals had any clinical signs of infection. Necropsy demonstrated an intact staple line with full-thickness healing of the gastrotomy in all animals. Histologic examination confirmed healing, but also revealed intramural micro-abscesses within the gastric wall after nonsterile procedure.Gastrotomy closure with a perorally delivered flexible stapling device created a leak-resistant transmural line of staples followed by full-thickness healing of the gastric wall incision. Increasing the length of the instrument and adding device articulation will further facilitate its use for NOTES procedures.
