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7228 Role of endoscopic ultrasonography in the diagnosis and staging of primary gastric lymphoma.
7225 ENTEROSCOPIC TREATMENT OF EARLY POSTOPERATIVE BOWEL OBSTRUCTION. Keith S. Gersin, Douglas N. Mellinger, Jeffrey L. Ponsky, Robert D. Fanelli, Berkshire Med Ctr, Pittsfield, MA; Cleveland Clin Fdn, Cleveland, OH. Introduction: Early postoperative small bowel obstruction (EPSBO) occurs in nearly 1% of patients undergoing laparotomy and has a mortality rate exceeding 17%. Nasogastric (NG) decompression is successful in 78% of patients. Repeat laparotomy has been recommended when obstruction does not resolve after 14 days of NG decompression. We report 4 patients with EPSBO treated successfully with push enteroscopy after failed NG decompression. Methods: Four patients who failed NG decompression underwent push enteroscopy instead of repeat laparotomy. EPSBO was diagnosed if obstruction lasting more than 14 days developed after initial resolution of postoperative ileus or high NG output persisted postoperatively for 21 days in the absence of prolonged ileus or sepsis. Small bowel series or CT was utilized when radiographic assessment was necessary. The Olympus SIF 100 push enteroscope was introduced with an overtube using topical anesthesia and intravenous sedation. After maximal insertion, the enteroscope was withdrawn without evacuation of insufflated air. NG tubes were placed after enteroscopy, and the patients followed clinically. Flatus, defecation, and tolerance of diet defined resolution of EPSBO. Results: EPSBO resolved 24-36 hours following enteroscopy, and all patients were discharged on general diets 48 hours after return of bowel function. Readmission has not been necessary during 6-18 month followup. Conclusions: Our experience suggests that push enteroscopy is successful in treating EPSBO and should be considered prior to re-operation. Repeat laparotomy may not be necessary and push enteroscopy may reduce patient morbidity, cost, and hospital lengths of stay associated with this uncommon surgical complication.
7227 METASTATIC INVOLVEMENT OF SMALL BOWEL. Stanislav Rejchrt, Karel Dedic, Pavel Zivny, Marcela Kopacova, Milan Siroky, Jan Bures, Clin Ctr - 2nd Internal Medicine Dept, Hradec Kralove, Czech Republic; Fingerland Institute of Pathology, Hradec Kralove, Czech Republic; Institute of Clin Biochemistry and Diagnostics, Hradec Kralove, Czech Republic. Background: Small bowel pathology is often difficult to be diagnosed. Enteroscopy is an important diagnostic and/or therapeutic method. Aim of the study is to evaluate significance of push enteroscopy in diagnostics of metastatic involvement of small bowel Methods. Within 5 years (19951999) 458 enteroscopy investigations were done (using push enteroscope Olympus SIF100 with or without overtube). Results. Metastatic involvement of small bowel was found in 8 patients (1.7 %). Two cases of malignant melanoma were found (the first one presenting as melena, the second one as a rapid weight loss). Other cases were as follows: pulmonary cancer metastasis (presenting as melena), teratoma (with microcytic anaemia), gastrinoma (MEN-I syndrome, hypergastrinaemia), carcinoid (melena, no endocrine activity), abdominal carcinomatous lymphadenopathy (with weight loss) and metachronous colon cancer (examined because of ileus). Conclusions: Metastatic involvement of small bowel is a rare condition, usually presenting of melena. Other clinical manifestation (microcytic anaemia, ileus, endocrine tumour activity or accidental finding) are less common.
7226 PUSH ENTEROSCOPY IN A MEDIUM-SIZED UK HOSPITAL. Sally D. Parry, Irving Cobden, John R. Barton, Mark R. Welfare, Univ of Newcastle, Newcastle, United Kingdom. Introduction: Push enteroscopy is a comparatively new endoscopy technique not routinely available in the UK. We have offered push enteroscopy to patients attending our hospital for 2 years. North Tyneside General Hospital serves a mixed urban population of approximately 200,000 people. In general it does not receive tertiary referrals, although the enteroscopy service has attracted some referrals from other hospitals outside our catchement area. Aims: To determine during a two year period the number of patients referred for enteroscopy from our own population and from further afield, the indication for referral, the diagnoses made and alterations to patient management. Methods: The medical notes of all 52 patients referred for enteroscopy during this period were reviewed. All except one underwent enteroscopy. 26 patients were referred from within the hospital and 26 from outside. Results: 26 referrals were made from our 200,000 population over a 2 year period. This suggests that there is a need for approximately 6-7 push enteroscopies per 100,000 people per year in our population. The indications for enteroscopy were: Obscure GI haemorrhage (n=32 with 19 acute and 13 chronic cases) Arteriovenous malformations (AVM’s) on initial endoscopy (n=7) Unexplained clinical deterioration in known coeliac disease (n=4) Abnormal small bowel follow through (n=5) Other; weight loss, diarrhoea +/- abdominal pain (n=4). Of the 51 patients undergoing enteroscopy, less than half (49%) were normal. Of the 26 abnormal enteroscopies, 7 had pathology in the stomach or first part of the duodenum (D1) that had not been diagnosed on initial OGD. Three had known AVM’s in the stomach or D1 only but none distally. There were 9 patients with small bowel AVM’s distal to D1 sufficient to explain their presentation and all were treated at enteroscopy. Important and unexpected diagnoses made were three cases of T cell lymphoma, two cases of coeliac disease, one of collagenous enteritis and one of jejunal adenocarcinoma. Conclusions: As in previous series, obscure GI bleeding, both acute and chronic, was the main indication for push enteroscopy and small bowel AVM’s were the most frequent finding. Push enteroscopy led to alterations in management in 51% of the cases and, as previously reported, missed abnormal findings within reach of OGD were frequent (14%). Although the need for push enteroscopy appears to be small, it would only take small changes in referral practice to increase this need significantly.
7228 ROLE OF ENDOSCOPIC ULTRASONOGRAPHY IN THE DIAGNOSIS AND STAGING OF PRIMARY GASTRIC LYMPHOMA. Biagini, Massimo Falchini, Marco Capanni, Monica Nuti, Calogero Surrenti, Gastroenterology Unit, Florence, Italy; Radiology Unit, Florence, Italy. Background and Study Aims: Endoscopic Ultrasonography (EUS)is currently indicated for evaluating gastric neoplasm, given its ability to visualize the lining of the stomach and to scan the wall and neighbouring tissues (organs, vessels, lymph nodes). We aimed to value the role of this technique in the diagnosis and staging of primary gastric lymphoma. Patients and Methods:We performed a retrospective study on 37 consecutive patients who had undergone EUS because of clinical suspicion for primary gastric lymphoma. The endoscopic ultrasound system used was Olympus GF-UM 20. Echoendoscopic findings were compared to histologic diagnosis from biopsies. For statistical analysis, the chi-square test was used. Results: Histologic evaluation of the endoscopic bioptic specimens diagnosed gastric lymphoma in 30/37 subjects; conventional biochemical and instrumental procedures excluded secondary disease of the stomach. EUS detected gastric lymphoma in a total of 27 patients, with no false positive results, therefore diagnostic rates were: sensitivity of 90%; specificity of 100%; positive predictability of 100%; negative predictability of 70%; diagnostic accuracy of 92%. All the 27 patients in whom EUS had disclosed lymphoma underwent endosonographic staging: in 25 patients who required medical treatment, EUS staging was compared with histological grading from biopsies, to which it showed a good correlation; in 2 patients who were to be operated on, it could be directly compared with pathologic post-operative examination of the resected speciments,resulting correct in both cases as regard tumor depth of infiltration (T1b), but overstaging 1 case as regards lymph node involvement (N1 on EUS, instead of N0). Conclusions:The diagnosis of gastric lymphoma is based on multiple endoscopic biopsies, with EUS providing a complementary evaluation, particularly helpful in difficult cases; in locoregional staging, on the other hand, endosonography plays a primary role, especially in exploring tumor depth of invasion.
VOLUME 51, NO. 4, PART 2, 2000
GASTROINTESTINAL ENDOSCOPY
AB299
7227 METASTATIC INVOLVEMENT OF SMALL BOWEL. Stanislav Rejchrt, Karel Dedic, Pavel Zivny, Marcela Kopacova, Milan Siroky, Jan Bures, Clin Ctr - 2nd Internal Medicine Dept, Hradec Kralove, Czech Republic; Fingerland Institute of Pathology, Hradec Kralove, Czech Republic; Institute of Clin Biochemistry and Diagnostics, Hradec Kralove, Czech Republic. Background: Small bowel pathology is often difficult to be diagnosed. Enteroscopy is an important diagnostic and/or therapeutic method. Aim of the study is to evaluate significance of push enteroscopy in diagnostics of metastatic involvement of small bowel Methods. Within 5 years (19951999) 458 enteroscopy investigations were done (using push enteroscope Olympus SIF100 with or without overtube). Results. Metastatic involvement of small bowel was found in 8 patients (1.7 %). Two cases of malignant melanoma were found (the first one presenting as melena, the second one as a rapid weight loss). Other cases were as follows: pulmonary cancer metastasis (presenting as melena), teratoma (with microcytic anaemia), gastrinoma (MEN-I syndrome, hypergastrinaemia), carcinoid (melena, no endocrine activity), abdominal carcinomatous lymphadenopathy (with weight loss) and metachronous colon cancer (examined because of ileus). Conclusions: Metastatic involvement of small bowel is a rare condition, usually presenting of melena. Other clinical manifestation (microcytic anaemia, ileus, endocrine tumour activity or accidental finding) are less common.
7226 PUSH ENTEROSCOPY IN A MEDIUM-SIZED UK HOSPITAL. Sally D. Parry, Irving Cobden, John R. Barton, Mark R. Welfare, Univ of Newcastle, Newcastle, United Kingdom. Introduction: Push enteroscopy is a comparatively new endoscopy technique not routinely available in the UK. We have offered push enteroscopy to patients attending our hospital for 2 years. North Tyneside General Hospital serves a mixed urban population of approximately 200,000 people. In general it does not receive tertiary referrals, although the enteroscopy service has attracted some referrals from other hospitals outside our catchement area. Aims: To determine during a two year period the number of patients referred for enteroscopy from our own population and from further afield, the indication for referral, the diagnoses made and alterations to patient management. Methods: The medical notes of all 52 patients referred for enteroscopy during this period were reviewed. All except one underwent enteroscopy. 26 patients were referred from within the hospital and 26 from outside. Results: 26 referrals were made from our 200,000 population over a 2 year period. This suggests that there is a need for approximately 6-7 push enteroscopies per 100,000 people per year in our population. The indications for enteroscopy were: Obscure GI haemorrhage (n=32 with 19 acute and 13 chronic cases) Arteriovenous malformations (AVM’s) on initial endoscopy (n=7) Unexplained clinical deterioration in known coeliac disease (n=4) Abnormal small bowel follow through (n=5) Other; weight loss, diarrhoea +/- abdominal pain (n=4). Of the 51 patients undergoing enteroscopy, less than half (49%) were normal. Of the 26 abnormal enteroscopies, 7 had pathology in the stomach or first part of the duodenum (D1) that had not been diagnosed on initial OGD. Three had known AVM’s in the stomach or D1 only but none distally. There were 9 patients with small bowel AVM’s distal to D1 sufficient to explain their presentation and all were treated at enteroscopy. Important and unexpected diagnoses made were three cases of T cell lymphoma, two cases of coeliac disease, one of collagenous enteritis and one of jejunal adenocarcinoma. Conclusions: As in previous series, obscure GI bleeding, both acute and chronic, was the main indication for push enteroscopy and small bowel AVM’s were the most frequent finding. Push enteroscopy led to alterations in management in 51% of the cases and, as previously reported, missed abnormal findings within reach of OGD were frequent (14%). Although the need for push enteroscopy appears to be small, it would only take small changes in referral practice to increase this need significantly.
7228 ROLE OF ENDOSCOPIC ULTRASONOGRAPHY IN THE DIAGNOSIS AND STAGING OF PRIMARY GASTRIC LYMPHOMA. Biagini, Massimo Falchini, Marco Capanni, Monica Nuti, Calogero Surrenti, Gastroenterology Unit, Florence, Italy; Radiology Unit, Florence, Italy. Background and Study Aims: Endoscopic Ultrasonography (EUS)is currently indicated for evaluating gastric neoplasm, given its ability to visualize the lining of the stomach and to scan the wall and neighbouring tissues (organs, vessels, lymph nodes). We aimed to value the role of this technique in the diagnosis and staging of primary gastric lymphoma. Patients and Methods:We performed a retrospective study on 37 consecutive patients who had undergone EUS because of clinical suspicion for primary gastric lymphoma. The endoscopic ultrasound system used was Olympus GF-UM 20. Echoendoscopic findings were compared to histologic diagnosis from biopsies. For statistical analysis, the chi-square test was used. Results: Histologic evaluation of the endoscopic bioptic specimens diagnosed gastric lymphoma in 30/37 subjects; conventional biochemical and instrumental procedures excluded secondary disease of the stomach. EUS detected gastric lymphoma in a total of 27 patients, with no false positive results, therefore diagnostic rates were: sensitivity of 90%; specificity of 100%; positive predictability of 100%; negative predictability of 70%; diagnostic accuracy of 92%. All the 27 patients in whom EUS had disclosed lymphoma underwent endosonographic staging: in 25 patients who required medical treatment, EUS staging was compared with histological grading from biopsies, to which it showed a good correlation; in 2 patients who were to be operated on, it could be directly compared with pathologic post-operative examination of the resected speciments,resulting correct in both cases as regard tumor depth of infiltration (T1b), but overstaging 1 case as regards lymph node involvement (N1 on EUS, instead of N0). Conclusions:The diagnosis of gastric lymphoma is based on multiple endoscopic biopsies, with EUS providing a complementary evaluation, particularly helpful in difficult cases; in locoregional staging, on the other hand, endosonography plays a primary role, especially in exploring tumor depth of invasion.
VOLUME 51, NO. 4, PART 2, 2000
GASTROINTESTINAL ENDOSCOPY
AB299