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A device for balloon tamponade of the duodenal bulb at endoscopy
31
of special note A device for balloon tamponade of the duodenal bulb at endoscopy David S. Zimmon, M.D. Veterans Administration Hospital 408 First Avenue New York, New York !OO!O During duodenal endoscopy for the emergency evaluation of upper gastrointestinal bleeding, visualization of a bleeding duodenal ulcer is common. A circumferential balloon attached to the endoscope allows immediate tamponade of the bleeding site and endoscopic evaluation of the result.
Figure 2: Radiography during tamponade with 50 ml balloon inflation in duodenal bulb. Sodium diawtrate 50% (Hypaque, Winthrop) injected through the endoscope outlines the distal duodenum and confirms pyloric obstruction during tamponade.
DESIGN An endotracheal cuff balloon (~ inch diameter) consists of the cuff balloon (5 cm in length), a filling tube, and a secondary monitoring balloon with its tubing. The monitoring balloon and its filling tube can be avulsed from the cuff balloon and its filling tube. Excess supporting rubber is trimmed from the proximal balloon adjacent to the filling tube. The distal portion of the balloon is cut to reduce overall length to 3.5 cm and resealed with rubber cement. The cuff balloon is then lubricated with water and slipped over the endoscope. The balloon is placed as distally as possible on the ACMI Gastroduodenoscope (Model FO7089, diameter 12mm) in order not to restrict the deflection mechanism. The proximal end of the supporting rubber
is securely tied to the endoscope under the filling tube. A tapered teflon tube (2.0 mm 0.0., 125 cm length) is pushed into the filling tube and its distal end fitted with a 3-way stop cock. The assembly is attached to the endoscope by the balloon. The teflon tube passively accompanies the endoscope. The balloon should fill and empty easily with 60 ml of air. The approximate diameter of balloonendoscope assembly after inflation ranges from 3 cm to 5 cm (15 ml=3.0 cm, 30 ml=3.8 cm, 45 ml=4.4 cm, 60 ml =4.8 cm). Deflection ofthe endoscope should not require increased force since a properly placed balloon assembly is distal to the deflection mechanism (Figure 1).
Figure 1: Endoscope and balloon assembly with 30 ml inflation. Maximum deflection of endoscope is not impeded by distally placed balloon.
TECHNIC After endoscopic visualization of the bleeding site in the proximal duodenal bulb, the endoscope is advanced into the first portion of the duodenum. The balloon within the duodenal bulb is inflated slowly with 15 ml to 30 ml of air or until the patient experiences pain. Traction is made on the endoscope to draw the balloon against the pylorus. With the pylorus obstructed the duodenum may be washed through the endoscope while traction is maintained (Figure 2). The control of hemorrhage is ascertained by the absence of blood passing distally. If bleeding continues traction may be increased or balloon inflation increased. Pressure is maintained for 10 to 20 minutes after bleeding is controlled. Traction is released and the duodenum inspected. If hemorrhage reCUITS, the procedure may be repeated or continued while the patient is stabilized and the operating facility prepared. In our laboratory, emergency endoscopy is performed using only local pharyngeal anesthesia. We consider the patient's response and lack of pain during the procedure as evidence that excess force is not being applied. Bleeding sites in the distal duodenum are not amenable to this technique. Therefore, the specific localization of the bleeding site previous to tamponade is essential. Clearly, a bleed-
VOLUME 20, NO.1, 1973
32
ing site in the stomach will continue unabated, and balloon tamponade of the pylorus will free the duodenum of blood. In the presence of massive hemorrhage that obscures endoscopic vision, a trial of duodenal tamponade may be attempted to define the post-pyloric location of bleeding. The potential consequences of continuous gastric bleeding during pyloric obstruction should be kept in mind. CASE REPORT A 38 year old white male was admitted to the Veterans Administration Hospital, New York, on 4 April, 1972 following hematemesis. Emergency endoscopy demonstrated a bleeding duodenal ulcer on the anterior wall of the bulb. Duodenal tamponade was attempted with 50 ml of air. The position of the balloon was confirmed by fluoroscopy and no evidence of distal bleeding was seen during balloon tamponade. After 17 minutes, traction was released and the balloon deflated. Inspection of the ulcer site demonstrated a clot without bleeding. Seventeen hours later, hemorrhage recurred, and the patient was taken to the operating room were a subtotal gastrectomy was performed. The operative specimen disclosed an uncomplicated duodenal ulcer with normal adjacent duodenal mucosal. Balloon tamponade temporarily controlled the hemorrhage from a duodenal ulcer in this patient and allowed a period of stabilization in hospital. Subsequent recurrence of hemorrhage was managed by emergency surgery.
Monilial esophagitis occurring in association with partial gastrectomy James W. Brown, M.D. Gastroenterology Section Wenatchee Valley Clinic P. O. Box 489 Wenatchee, Washington 98801
Monilial esophagitis is generally considered to occur secondary to debilitating illness, hematologic or lymphatic malignancy, or in cases of decreased immunologic resistence secondary to immunosuppressive or longterm antibiotic therapy .1-7 A case of acute monilial esophagitis in an apparent healthy young male has been recently reported by this author. 8 The following case report documents monilial esophagitis occurring in a patient with Bilroth I gastric resection. This case is reported to reemphasize the fact that this disease can occur in apparently healthy people and unless recognized may go untreated. CASE REPORT A 46 year old male presented with a chief complaint of painful swallowing, progressively worsening over the previous 6 months. Thirteen years before he underwent a 60% gastric resection for ulcer disease causing a massive upper gastrointestinal hemorrhage. No vagotomy was carried out to his knowledge. Two years later he had another upper gastrointestinal hemorrhage with
hematemesis and melena which required no transfusions. Since that time he had intermittent symptoms of regurgitation of food and easy filling. He denied abdominal pain and did not use salicylates, alcohol, or coffee and had been on no antibiotics. He denied bloody stools, diarrhea, or weight loss. In recent months he had no upper abdominal symptoms but primarily complained of the painful dysphagia. The physical examination was entirely unremarkable; there were no oral-pharyngeal lesions. Upper gastrointestinal radiographs showed no abnormalities of the esophagus but did show some fluid and food retention within the stomach but with normal emptying of the barium. All laboratory values including immunoglobulin electrophoresis were normal. Endoscopy was performed with the Olympus G IF instrument. Throughout the midesophagus, extending down toward the cardia, there was a diffuse, erythematous, nonulcerated, inflammatory reaction with cheesy exudate over it. ~hree biopsies were taken at 20 cm to 25 cm from the alv lar ridge. Scrapings were taken for cytology and for cult re on Sabouraud's medium. There was bile-stained fluid within the stomach without any sign of excessive fluid accumulation or retained food. The anastamosis was normal except for marked zonal gastritis, probably due to alkaline reflux. The duodenum was normal. The cultures of the esophagus showed a heavy growth of Candida albicans and cytology showed class II atypical cells. The biopsies showed reactive inflammatory infiltrate present beneath the epithelium and methenamine silver stains revealed fungal hyphae within the tissue that was consistent with monilia. The pathologist interpreted this as chronic active esophagitis with fungal elements within the tissue. On a basis of the endoscopic findings, the patient was given Mycostatin oral suspension in a methycellulose suspension, 1 ml 4 times daily. Within 24 hours his painful dysphagia, which had been present for many months, had entirely disappeared. On later followup the patient was symptom-free. DISCUSSION Candida albicans, a saprophytic organism and limited pathogen, is present normally in the mouth and colon but there are no reports of its normal occurrence in the esophagus. 8 Presently we are conducting a prospective search for Candida in the distal esophagus in patients endoscoped without esophageal symptoms. Our patient represents the first case of monilial esophagitis reported in relation to previous gastric resection. This patient denied any recent symptoms relating to his stomach and complained only of painful dysphagia. Whether or not the previous gastric surgery played a role in the development of the esopagitis is speculative. No other cause for its development was apparent by physical, roentgenologic, or laboratory examination. A hypotensive gastroesophageal sphincter after gastrectomy allowing reflux can lead to symptoms of heartburn from bile esophagitis. 9- lo This might have predisposed the patient to a secondary infection with Monilia; however, he had no symptoms for 12 years following his operation. The rapid response to Mycostatin and the findings of the inflammation most prominent in the midespphagus in this patient would discount the role of bile reflux as a cause of the patient's symptoms. GASTROINTESTINAL ENDOSCOPY
of special note A device for balloon tamponade of the duodenal bulb at endoscopy David S. Zimmon, M.D. Veterans Administration Hospital 408 First Avenue New York, New York !OO!O During duodenal endoscopy for the emergency evaluation of upper gastrointestinal bleeding, visualization of a bleeding duodenal ulcer is common. A circumferential balloon attached to the endoscope allows immediate tamponade of the bleeding site and endoscopic evaluation of the result.
Figure 2: Radiography during tamponade with 50 ml balloon inflation in duodenal bulb. Sodium diawtrate 50% (Hypaque, Winthrop) injected through the endoscope outlines the distal duodenum and confirms pyloric obstruction during tamponade.
DESIGN An endotracheal cuff balloon (~ inch diameter) consists of the cuff balloon (5 cm in length), a filling tube, and a secondary monitoring balloon with its tubing. The monitoring balloon and its filling tube can be avulsed from the cuff balloon and its filling tube. Excess supporting rubber is trimmed from the proximal balloon adjacent to the filling tube. The distal portion of the balloon is cut to reduce overall length to 3.5 cm and resealed with rubber cement. The cuff balloon is then lubricated with water and slipped over the endoscope. The balloon is placed as distally as possible on the ACMI Gastroduodenoscope (Model FO7089, diameter 12mm) in order not to restrict the deflection mechanism. The proximal end of the supporting rubber
is securely tied to the endoscope under the filling tube. A tapered teflon tube (2.0 mm 0.0., 125 cm length) is pushed into the filling tube and its distal end fitted with a 3-way stop cock. The assembly is attached to the endoscope by the balloon. The teflon tube passively accompanies the endoscope. The balloon should fill and empty easily with 60 ml of air. The approximate diameter of balloonendoscope assembly after inflation ranges from 3 cm to 5 cm (15 ml=3.0 cm, 30 ml=3.8 cm, 45 ml=4.4 cm, 60 ml =4.8 cm). Deflection ofthe endoscope should not require increased force since a properly placed balloon assembly is distal to the deflection mechanism (Figure 1).
Figure 1: Endoscope and balloon assembly with 30 ml inflation. Maximum deflection of endoscope is not impeded by distally placed balloon.
TECHNIC After endoscopic visualization of the bleeding site in the proximal duodenal bulb, the endoscope is advanced into the first portion of the duodenum. The balloon within the duodenal bulb is inflated slowly with 15 ml to 30 ml of air or until the patient experiences pain. Traction is made on the endoscope to draw the balloon against the pylorus. With the pylorus obstructed the duodenum may be washed through the endoscope while traction is maintained (Figure 2). The control of hemorrhage is ascertained by the absence of blood passing distally. If bleeding continues traction may be increased or balloon inflation increased. Pressure is maintained for 10 to 20 minutes after bleeding is controlled. Traction is released and the duodenum inspected. If hemorrhage reCUITS, the procedure may be repeated or continued while the patient is stabilized and the operating facility prepared. In our laboratory, emergency endoscopy is performed using only local pharyngeal anesthesia. We consider the patient's response and lack of pain during the procedure as evidence that excess force is not being applied. Bleeding sites in the distal duodenum are not amenable to this technique. Therefore, the specific localization of the bleeding site previous to tamponade is essential. Clearly, a bleed-
VOLUME 20, NO.1, 1973
32
ing site in the stomach will continue unabated, and balloon tamponade of the pylorus will free the duodenum of blood. In the presence of massive hemorrhage that obscures endoscopic vision, a trial of duodenal tamponade may be attempted to define the post-pyloric location of bleeding. The potential consequences of continuous gastric bleeding during pyloric obstruction should be kept in mind. CASE REPORT A 38 year old white male was admitted to the Veterans Administration Hospital, New York, on 4 April, 1972 following hematemesis. Emergency endoscopy demonstrated a bleeding duodenal ulcer on the anterior wall of the bulb. Duodenal tamponade was attempted with 50 ml of air. The position of the balloon was confirmed by fluoroscopy and no evidence of distal bleeding was seen during balloon tamponade. After 17 minutes, traction was released and the balloon deflated. Inspection of the ulcer site demonstrated a clot without bleeding. Seventeen hours later, hemorrhage recurred, and the patient was taken to the operating room were a subtotal gastrectomy was performed. The operative specimen disclosed an uncomplicated duodenal ulcer with normal adjacent duodenal mucosal. Balloon tamponade temporarily controlled the hemorrhage from a duodenal ulcer in this patient and allowed a period of stabilization in hospital. Subsequent recurrence of hemorrhage was managed by emergency surgery.
Monilial esophagitis occurring in association with partial gastrectomy James W. Brown, M.D. Gastroenterology Section Wenatchee Valley Clinic P. O. Box 489 Wenatchee, Washington 98801
Monilial esophagitis is generally considered to occur secondary to debilitating illness, hematologic or lymphatic malignancy, or in cases of decreased immunologic resistence secondary to immunosuppressive or longterm antibiotic therapy .1-7 A case of acute monilial esophagitis in an apparent healthy young male has been recently reported by this author. 8 The following case report documents monilial esophagitis occurring in a patient with Bilroth I gastric resection. This case is reported to reemphasize the fact that this disease can occur in apparently healthy people and unless recognized may go untreated. CASE REPORT A 46 year old male presented with a chief complaint of painful swallowing, progressively worsening over the previous 6 months. Thirteen years before he underwent a 60% gastric resection for ulcer disease causing a massive upper gastrointestinal hemorrhage. No vagotomy was carried out to his knowledge. Two years later he had another upper gastrointestinal hemorrhage with
hematemesis and melena which required no transfusions. Since that time he had intermittent symptoms of regurgitation of food and easy filling. He denied abdominal pain and did not use salicylates, alcohol, or coffee and had been on no antibiotics. He denied bloody stools, diarrhea, or weight loss. In recent months he had no upper abdominal symptoms but primarily complained of the painful dysphagia. The physical examination was entirely unremarkable; there were no oral-pharyngeal lesions. Upper gastrointestinal radiographs showed no abnormalities of the esophagus but did show some fluid and food retention within the stomach but with normal emptying of the barium. All laboratory values including immunoglobulin electrophoresis were normal. Endoscopy was performed with the Olympus G IF instrument. Throughout the midesophagus, extending down toward the cardia, there was a diffuse, erythematous, nonulcerated, inflammatory reaction with cheesy exudate over it. ~hree biopsies were taken at 20 cm to 25 cm from the alv lar ridge. Scrapings were taken for cytology and for cult re on Sabouraud's medium. There was bile-stained fluid within the stomach without any sign of excessive fluid accumulation or retained food. The anastamosis was normal except for marked zonal gastritis, probably due to alkaline reflux. The duodenum was normal. The cultures of the esophagus showed a heavy growth of Candida albicans and cytology showed class II atypical cells. The biopsies showed reactive inflammatory infiltrate present beneath the epithelium and methenamine silver stains revealed fungal hyphae within the tissue that was consistent with monilia. The pathologist interpreted this as chronic active esophagitis with fungal elements within the tissue. On a basis of the endoscopic findings, the patient was given Mycostatin oral suspension in a methycellulose suspension, 1 ml 4 times daily. Within 24 hours his painful dysphagia, which had been present for many months, had entirely disappeared. On later followup the patient was symptom-free. DISCUSSION Candida albicans, a saprophytic organism and limited pathogen, is present normally in the mouth and colon but there are no reports of its normal occurrence in the esophagus. 8 Presently we are conducting a prospective search for Candida in the distal esophagus in patients endoscoped without esophageal symptoms. Our patient represents the first case of monilial esophagitis reported in relation to previous gastric resection. This patient denied any recent symptoms relating to his stomach and complained only of painful dysphagia. Whether or not the previous gastric surgery played a role in the development of the esopagitis is speculative. No other cause for its development was apparent by physical, roentgenologic, or laboratory examination. A hypotensive gastroesophageal sphincter after gastrectomy allowing reflux can lead to symptoms of heartburn from bile esophagitis. 9- lo This might have predisposed the patient to a secondary infection with Monilia; however, he had no symptoms for 12 years following his operation. The rapid response to Mycostatin and the findings of the inflammation most prominent in the midespphagus in this patient would discount the role of bile reflux as a cause of the patient's symptoms. GASTROINTESTINAL ENDOSCOPY