- Email: [email protected]
Endoscopic ultrasound assisted resection of duodenal non-ampullary adenomas
AJG – September, 2000
Abstracts
transplant has become a life saving treatment with excellent long-term rehabilitation for patients with irreversible intestinal failure.
272 6-Thioguanine levels versus white blood cell counts in guiding 6mercaptopurine and azathioprine therapy JP Achkar, MD, T Stevens, MD, A Brzezinski, MD, FACG, D Seidner, MD, FACG, B Lashner, MD, FACG. Cleveland Clinic Foundation, Cleveland, OH. Purpose: A recently published study demonstrated that serum 6-thioguanine levels (6-TG) ⬎235 pmol/8 ⫻ 108 RBCs correlated with clinical response in pediatric patients with inflammatory bowel disease (IBD). Our aim was to assess the association between 6-TG, white blood cell counts (WBC), and clinical response in adult IBD patients. Methods: 45 patients with IBD who were on stable doses of six-mercaptopurine (6-MP) or azathioprine (AZA) for at least 3 months were evaluated. 6-TG levels and WBC were measured as part of routine clinical care. Patients were classified as responders (N ⫽ 19), non-responders (N ⫽ 18), or in continued remission (N ⫽ 8) based on clinical criteria. Results: Responders Median 6-TG 6-TG ⬎ 235 6-TG ⬎ 260 Median WBC WBC ⬍ 5.0 Median 6-MP dose Median AZA dose
302 16 (84%) 15 (79%) 4.9 10/18 (56%) 1.50 mg/kg 1.60 mg/kg
Non-Responders
P-value
179 8 (44%) 5 (28%) 7.0 4/14 (29%) 0.95 mg/kg 1.65 mg/kg
0.004 0.02 0.006 0.02 0.2 0.03 0.3
Maximal difference between responders and non-responders was seen at 6-TG levels ⬎260. There was a significant inverse correlation between 6-TG level and WBC (Spearman correlation coefficient ⫽ ⫺0.35; P ⫽ 0.03) but no relationship was found between drug dose and 6-TG levels (Spearman correlation coefficient ⫽ 0.11; P ⫽ 0.5). Conclusions: 1. 6-TG levels are associated with clinical response and, in our population, maximal differentiation between responders and non-responders is seen at 6-TG levels ⬎ 260. 2. 6-TG levels appear to be better predictors of clinical response than leukopenia. 3. Measurement of 6-TG levels is helpful in tailoring therapy with 6-MP and AZA especially in non-responders.
273 Foeniculum vulgare therapy in irritable bowel syndrome Hassan Amjad, MD, HA Jafary, MD. Beckley, WV. IBS is a chronic disorder with stomach pain, bloating and abnormal bowel movements, often refractory to conventional treatment with pts having a feeling of poor quality of life. Herbal therapy with Foeniculum vulgare (Fennel seed), offers new therapeutic modality. IBS is 2nd important cause of work absenteeism after common colds and affects 9.4% of Americans. Conventional therapy consists of high fiber diet antispasmodics like hyocyamine and dicyclomine which benefit some pts however, the majority remain symptomatic. They have more frequent visits to hospitals, physicians, more abdominal surgeries, procedures and dependence on analgesics. IBS is not a new disease and similar functional bowel dysfunctions were treated with FV seeds in the ancient writing of AVICENNA and RHAZES, and in medieval English herbal remedies. Five pts with IBS meeting Rome criteria, who were poor responders to available therapies were selected for FV treatment. These pts were given special sugar coated 4 FV seeds to chew and swallow after meals for one week then increasing gradually the
2491
dose to 8 –12 seeds three times a day. Following IBS activity markers, were used for comparison before and after therapy. Frequency and regularity of BMS, number of visits to medical provider, abdominal pain and spasm, excessive bloating and dependence on pain medicine. After 2 weeks of therapy, there were marked improvement with less abdominal cramps, less dependence on laxative, Imodium, analgesics and less visits to physicians. Pts felt that they had more control of their social life. Fennel seeds extract contain essential oils like trans—trans-anethole and fechone which exhibit its spasmolytic effect through plant based Ca Channel blocker. It has also estrogenic and psychodelic adrenalin like effect. Fennel seeds should be considered as a useful adjunctive therapeutic modality in refractory cases of IBS. It effectively controls many symptoms of IBS with significant overall improvement in quality of life.
274 The effect of abdominal palpation on gastrointestinal sounds (GIS) in healthy subjects: A quantitative investigation using computerized analysis Terence L Angtuaco, Jennifer Evans, Laura Harrell, Hussein A Mansy, Richard H Sandler*. Rush University, Chicago, IL. Purpose: To determine whether gastrointestinal sounds are altered when abdominal palpation is performed before auscultation. Although it has long been taught that auscultation of the abdomen should precede palpation in order not to affect gastrointestinal sounds, there is no evidence in the literature supporting this teaching. Methods: We enrolled 40 healthy subjects in the study. A single investigator applied moderately firm abdominal palpation to each of the nine abdominal regions for a total of one minute. We placed a three-sensor custom harness on each subject’s abdomen and recorded pre- and postpalpation gastrointestinal sounds (GIS) for 10 minutes each on an analog audio tape recorder. Our previous experience in 220 subjects showed the GIS spectrum to lie within the 100 –1000 Hz acoustic bandwidth; hence, signals were high- and low-band pass filtered at these frequencies and digitized at 4096 Hz. We used custom software to identify the number of GIS event per minute, characterizing separately their duration (milliseconds), dominant frequency (“pitch” in Hz) and amplitude (millivolts). Results: There were no significant differences in the number of GIS events per minute, duration, dominant frequency and amplitude between pre- and post-palpation recordings. The findings from all three sensors were consistent. Conclusions: Abdominal palpation before auscultation does not influence gastrointestinal sounds in healthy subjects. If these findings are confirmed in patients with gastrointestinal illnesses, auscultation need not precede abdominal palpation during physical examination.
275 Endoscopic ultrasound assisted resection of duodenal non-ampullary adenomas Mohammed Barawi, Frank Gress, Alan Lipp, Steve Geier, James Grendell*. State University of New York, Stony Brook, NY. Purpose: Non-ampullary duodenal adenomas are rare. There is limited data in the literature regarding endoscopic management. The purpose of the study is to report our own experience with the endoscopic management of such lesions. Methods: Eight consecutive patients (5M/3F) with a mean age of 68 years (range 60 – 84) were referred to our institution for endoscopic management of non-ampullary duodenal polypoid lesions. These were sessile lesions, measuring 1– 4 cm (mean 2.3 cm). The pathology of these lesions were tubular adenoma (5), tubulovillous adenoma (2) and one villous adenoma with high grade dysplasia. EUS was performed on all lesions to determine depth of invasion. All lesions were superficial with no involvement beyond
2492
Abstracts
the submucosal layer. After EUS, saline and epinephrine (1/10,000 solution) was injected to elevate these lesions, followed by snare piecemeal resection using a diathermy snare. Cauterization of the base of the lesion was then performed using argon plasma coagulation (60 wt, 1.0 L/min). Results: All lesions were successfully removed in 1–3 sessions (mean 1.2 sessions). We placed a pancreatic stent in one case prior to endoscopic therapy as the lesion was close to the papilla. No complications were reported. Follow up endoscopy after 8 –12 months (mean 10 months) showed no recurrence of these adenomas. Conclusions: Non-ampullary duodenal adenomas and carcinoma in situ can be successfully treated by endoscopic means. EUS provides detailed information on the depth of invasion prior to endoscopic therapy. A combination of snare polypectomy and argon plasma coagulation appears to be useful in managing these lesions.
276 Mycophenolate mofetil-associated gastrointestinal hemorrhage in renal transplant recipients, a 3 year prospective evaluation of clinical and endoscopic findings at a large community transplant center RM Bashir, MD, S Ressaiah, MD, M Ali, MD, O Grandes, MD, S Karokozis, MD, M White, T Sasaki, MD, A Aquino, J Light, MD. Depts. of Medicine and Surgery, Washington Hospital Center, Washington, DC. Background: Mycophenolate mofetil (CellCept; Roche Pharmaceuticals, Nutley, NJ) has been associated with gastrointestinal (GI) hemorrhage; however, prospective clinical findings have not been reported. Methods: From December 1996 through December 1999, renal transplant recipients receiving CellCept who presented with GI bleeding were identified. All patients underwent upper endoscopy (EGD) and, if negative, colonoscopy for evaluation of GI bleeding. Patients with a history of peptic ulcer disease, prior to GI bleeding, and patients on nonsteroidal antiinflammatory (NSAIDs) medications were excluded. All patients subsequently included for analysis were biopsy negative for H. pylori and viral culture negative. Results: During the 36 month study period, 267 transplant recipients received CellCept. Among 23 patients (8.6%) receiving CellCept who presented with GI bleeding, 7 were excluded: NSAIDs (3); H. pylori (1); prior GI bleeding (1); CMV biopsy or culture positive (2). Of the 16 patients included (6.2% overall), 12 (75%) presented predominantly with melena; 4 (25%) with hematochezia. All 16 patients underwent EGD; 10/16 also underwent colonoscopy. EGD demonstrated distinct raised, friable gastric antral nodules with ulceration in 10/16 patients (62.5%), esophageal erosions in one (6%), and duodenal ulcer in one (6%). Colonoscopy demonstrated ileocecal valve ulceration in 6/10 patients (60%) (with additional cecal ulcers in 2/6), and was negative in 40%. Patients presenting with melena tended to be receiving CellCept for a shorter average duration from transplant to initial GI bleeding episode than those presenting with hematochezia (76 vs 164 days). Discontinuation of CellCept led to cessation of GI bleeding in all patients. Conclusions: The prospective incidence of CellCept-associated GI bleeding (8.6% overall) was higher than that reported in prerelease clinical trials (3%) and occurred relatively soon after transplantation (usually 2– 6 months). Distinct endoscopic findings, gastric ulcerated nodules and/or ileocecal valve ulcers, accounted for 14/16 (88%) of all cases. CellCept should be considered a likely and endoscopically identifiable cause of GI bleeding in renal transplant recipients.
277 Turbulent two phase flow; a novel method for cleaning and high grade disinfection of flexible endoscopies and internal channels Stanley Benjamin, MD, Mohamed Labib, Ph.D. Georgetown University and Novaflux Technologies, Washington, DC and Princeton, NJ.
AJG – Vol. 95, No. 9, 2000
One of the major obstacles to high grade disinfection (HGD) of flexible endoscopies is the biofilm layer that forms on the internal channels of flexible endoscopies (FE). Recently introduced, turbulent two phased flow (TTFF), has been shown to eliminate biofilm from the inside of dental tubing and other long tubular channels. Preliminary work has demonstrated the ability of this technology to remove biofilm from endoscope channels. Aim: To determine the ability of TTFF to provide high level disinfection (⬎106 reduction in organisms) to endoscopies and endoscope channels. Methods: Two previously used endoscopes and two endoscope channels were provided by Pentax Precision Instrument Co., Orangeburg, NY). The endoscopes and channels were contaminated with B. subtilis var. niger at a concentration of 107 CFU/scope and channel by an independent laboratory (Nelson Labs, Inc., Salt Lake City, UT). Scopes and channels were processed using two phase flow of air and surfactant/detergent mixture by Novaflux technologies, Inc. (Princeton, NJ) and sent to Nelson Labs for evaluation. Results:
#1 air/water #1 suction/bx #2 air/water #2 suction/bx* control
Cts/initial
Cts/post-TTFF
% reduction
Log reduction
7.0 ⫻ 10 7.0 ⫻ 107 7.0 ⫻ 107 7.0 ⫻ 107 7.0 ⫻ 107
20 43.7 20 436.6 7 ⫻ 107
⬎99.9% ⬎99.9% ⬎99.9% ⬎99.9% 0
6.1 6.2 6.1 5.2 0
7
* post procedure a leak was found in the channel.
Conclusions: 1) At a minimum TTFF can provide mechanical cleansing of endoscopes, eliminating the need for committed staff and reducing the risk of non-compliance; 2) with appropriate design modifications the technology appears to be able to provide HLD; 3) damaged endoscope channels cannot be cleaned/disinfected appropriately.
278 Changing etiology of upper GI bleeding in AIDS patients Faraz F Berjis, Adnan M Khdair*, Irwin M Grosman. Long Island College Hospital, Brooklyn, NY. Purpose: To compare the etiology of upper GI bleeding (UGIB) in AIDS patients during two time intervals and to assess the impact of contemporary HIV therapy on etiology and prognosis. Methods: Retrospective analysis of 50 patients with AIDS as defined by the CDC criteria who presented to a single center with UGIB (hematemesis and/or melena with a positive nasogastric lavage) and were evaluated by upper endoscopy. Group 1 consists of 27 patients evaluated from 1987– 1993 and group 2 consists of 23 patients from 1996 –2000. Results: 12/27 patients in group 1 (44%) had an AIDS related etiology for the UGIB (8 Candida esophagitis, 3 idiopathic esophageal ulcer and 1 with Kaposi’s sarcoma) while only 1 patient from group 2 (4%) had an AIDS related diagnosis (CMV gastric ulcer). The first group had 15 non-AIDS related causes for UGIB (7 gastric ulcer, 5 erosive gastritis, 2 MalloryWeiss tear and 1 duodenal ulcer). The second group had 22 non-AIDS related causes for UGIB as follows: 9 gastric ulcer, 4 erosive esophagitis, 4 erosive gastritis, 2 duodenitis, 2 bleeding esophageal varices, and 1 Mallory-Weiss tear. The 7 day mortality was 11% in the first group compared to 0% in the second group. Conclusions: We observed a changing pattern of etiology for UGIB in our 2 series of patients with AIDS. Our earlier cohort had a high prevalence of AIDS related causes for GI bleeding while our recent patients had bleeding from causes similar to the general hospitalized population. With better therapy of HIV disease the pattern of UGIB in AIDS patients is changing to become similar to their non-HIV infected peers. The study also shows improved short term mortality in these patients and confirms our previous conclusion that UGIB in AIDS is not a terminal event and these patients should be promptly assessed and treated.
Abstracts
transplant has become a life saving treatment with excellent long-term rehabilitation for patients with irreversible intestinal failure.
272 6-Thioguanine levels versus white blood cell counts in guiding 6mercaptopurine and azathioprine therapy JP Achkar, MD, T Stevens, MD, A Brzezinski, MD, FACG, D Seidner, MD, FACG, B Lashner, MD, FACG. Cleveland Clinic Foundation, Cleveland, OH. Purpose: A recently published study demonstrated that serum 6-thioguanine levels (6-TG) ⬎235 pmol/8 ⫻ 108 RBCs correlated with clinical response in pediatric patients with inflammatory bowel disease (IBD). Our aim was to assess the association between 6-TG, white blood cell counts (WBC), and clinical response in adult IBD patients. Methods: 45 patients with IBD who were on stable doses of six-mercaptopurine (6-MP) or azathioprine (AZA) for at least 3 months were evaluated. 6-TG levels and WBC were measured as part of routine clinical care. Patients were classified as responders (N ⫽ 19), non-responders (N ⫽ 18), or in continued remission (N ⫽ 8) based on clinical criteria. Results: Responders Median 6-TG 6-TG ⬎ 235 6-TG ⬎ 260 Median WBC WBC ⬍ 5.0 Median 6-MP dose Median AZA dose
302 16 (84%) 15 (79%) 4.9 10/18 (56%) 1.50 mg/kg 1.60 mg/kg
Non-Responders
P-value
179 8 (44%) 5 (28%) 7.0 4/14 (29%) 0.95 mg/kg 1.65 mg/kg
0.004 0.02 0.006 0.02 0.2 0.03 0.3
Maximal difference between responders and non-responders was seen at 6-TG levels ⬎260. There was a significant inverse correlation between 6-TG level and WBC (Spearman correlation coefficient ⫽ ⫺0.35; P ⫽ 0.03) but no relationship was found between drug dose and 6-TG levels (Spearman correlation coefficient ⫽ 0.11; P ⫽ 0.5). Conclusions: 1. 6-TG levels are associated with clinical response and, in our population, maximal differentiation between responders and non-responders is seen at 6-TG levels ⬎ 260. 2. 6-TG levels appear to be better predictors of clinical response than leukopenia. 3. Measurement of 6-TG levels is helpful in tailoring therapy with 6-MP and AZA especially in non-responders.
273 Foeniculum vulgare therapy in irritable bowel syndrome Hassan Amjad, MD, HA Jafary, MD. Beckley, WV. IBS is a chronic disorder with stomach pain, bloating and abnormal bowel movements, often refractory to conventional treatment with pts having a feeling of poor quality of life. Herbal therapy with Foeniculum vulgare (Fennel seed), offers new therapeutic modality. IBS is 2nd important cause of work absenteeism after common colds and affects 9.4% of Americans. Conventional therapy consists of high fiber diet antispasmodics like hyocyamine and dicyclomine which benefit some pts however, the majority remain symptomatic. They have more frequent visits to hospitals, physicians, more abdominal surgeries, procedures and dependence on analgesics. IBS is not a new disease and similar functional bowel dysfunctions were treated with FV seeds in the ancient writing of AVICENNA and RHAZES, and in medieval English herbal remedies. Five pts with IBS meeting Rome criteria, who were poor responders to available therapies were selected for FV treatment. These pts were given special sugar coated 4 FV seeds to chew and swallow after meals for one week then increasing gradually the
2491
dose to 8 –12 seeds three times a day. Following IBS activity markers, were used for comparison before and after therapy. Frequency and regularity of BMS, number of visits to medical provider, abdominal pain and spasm, excessive bloating and dependence on pain medicine. After 2 weeks of therapy, there were marked improvement with less abdominal cramps, less dependence on laxative, Imodium, analgesics and less visits to physicians. Pts felt that they had more control of their social life. Fennel seeds extract contain essential oils like trans—trans-anethole and fechone which exhibit its spasmolytic effect through plant based Ca Channel blocker. It has also estrogenic and psychodelic adrenalin like effect. Fennel seeds should be considered as a useful adjunctive therapeutic modality in refractory cases of IBS. It effectively controls many symptoms of IBS with significant overall improvement in quality of life.
274 The effect of abdominal palpation on gastrointestinal sounds (GIS) in healthy subjects: A quantitative investigation using computerized analysis Terence L Angtuaco, Jennifer Evans, Laura Harrell, Hussein A Mansy, Richard H Sandler*. Rush University, Chicago, IL. Purpose: To determine whether gastrointestinal sounds are altered when abdominal palpation is performed before auscultation. Although it has long been taught that auscultation of the abdomen should precede palpation in order not to affect gastrointestinal sounds, there is no evidence in the literature supporting this teaching. Methods: We enrolled 40 healthy subjects in the study. A single investigator applied moderately firm abdominal palpation to each of the nine abdominal regions for a total of one minute. We placed a three-sensor custom harness on each subject’s abdomen and recorded pre- and postpalpation gastrointestinal sounds (GIS) for 10 minutes each on an analog audio tape recorder. Our previous experience in 220 subjects showed the GIS spectrum to lie within the 100 –1000 Hz acoustic bandwidth; hence, signals were high- and low-band pass filtered at these frequencies and digitized at 4096 Hz. We used custom software to identify the number of GIS event per minute, characterizing separately their duration (milliseconds), dominant frequency (“pitch” in Hz) and amplitude (millivolts). Results: There were no significant differences in the number of GIS events per minute, duration, dominant frequency and amplitude between pre- and post-palpation recordings. The findings from all three sensors were consistent. Conclusions: Abdominal palpation before auscultation does not influence gastrointestinal sounds in healthy subjects. If these findings are confirmed in patients with gastrointestinal illnesses, auscultation need not precede abdominal palpation during physical examination.
275 Endoscopic ultrasound assisted resection of duodenal non-ampullary adenomas Mohammed Barawi, Frank Gress, Alan Lipp, Steve Geier, James Grendell*. State University of New York, Stony Brook, NY. Purpose: Non-ampullary duodenal adenomas are rare. There is limited data in the literature regarding endoscopic management. The purpose of the study is to report our own experience with the endoscopic management of such lesions. Methods: Eight consecutive patients (5M/3F) with a mean age of 68 years (range 60 – 84) were referred to our institution for endoscopic management of non-ampullary duodenal polypoid lesions. These were sessile lesions, measuring 1– 4 cm (mean 2.3 cm). The pathology of these lesions were tubular adenoma (5), tubulovillous adenoma (2) and one villous adenoma with high grade dysplasia. EUS was performed on all lesions to determine depth of invasion. All lesions were superficial with no involvement beyond
2492
Abstracts
the submucosal layer. After EUS, saline and epinephrine (1/10,000 solution) was injected to elevate these lesions, followed by snare piecemeal resection using a diathermy snare. Cauterization of the base of the lesion was then performed using argon plasma coagulation (60 wt, 1.0 L/min). Results: All lesions were successfully removed in 1–3 sessions (mean 1.2 sessions). We placed a pancreatic stent in one case prior to endoscopic therapy as the lesion was close to the papilla. No complications were reported. Follow up endoscopy after 8 –12 months (mean 10 months) showed no recurrence of these adenomas. Conclusions: Non-ampullary duodenal adenomas and carcinoma in situ can be successfully treated by endoscopic means. EUS provides detailed information on the depth of invasion prior to endoscopic therapy. A combination of snare polypectomy and argon plasma coagulation appears to be useful in managing these lesions.
276 Mycophenolate mofetil-associated gastrointestinal hemorrhage in renal transplant recipients, a 3 year prospective evaluation of clinical and endoscopic findings at a large community transplant center RM Bashir, MD, S Ressaiah, MD, M Ali, MD, O Grandes, MD, S Karokozis, MD, M White, T Sasaki, MD, A Aquino, J Light, MD. Depts. of Medicine and Surgery, Washington Hospital Center, Washington, DC. Background: Mycophenolate mofetil (CellCept; Roche Pharmaceuticals, Nutley, NJ) has been associated with gastrointestinal (GI) hemorrhage; however, prospective clinical findings have not been reported. Methods: From December 1996 through December 1999, renal transplant recipients receiving CellCept who presented with GI bleeding were identified. All patients underwent upper endoscopy (EGD) and, if negative, colonoscopy for evaluation of GI bleeding. Patients with a history of peptic ulcer disease, prior to GI bleeding, and patients on nonsteroidal antiinflammatory (NSAIDs) medications were excluded. All patients subsequently included for analysis were biopsy negative for H. pylori and viral culture negative. Results: During the 36 month study period, 267 transplant recipients received CellCept. Among 23 patients (8.6%) receiving CellCept who presented with GI bleeding, 7 were excluded: NSAIDs (3); H. pylori (1); prior GI bleeding (1); CMV biopsy or culture positive (2). Of the 16 patients included (6.2% overall), 12 (75%) presented predominantly with melena; 4 (25%) with hematochezia. All 16 patients underwent EGD; 10/16 also underwent colonoscopy. EGD demonstrated distinct raised, friable gastric antral nodules with ulceration in 10/16 patients (62.5%), esophageal erosions in one (6%), and duodenal ulcer in one (6%). Colonoscopy demonstrated ileocecal valve ulceration in 6/10 patients (60%) (with additional cecal ulcers in 2/6), and was negative in 40%. Patients presenting with melena tended to be receiving CellCept for a shorter average duration from transplant to initial GI bleeding episode than those presenting with hematochezia (76 vs 164 days). Discontinuation of CellCept led to cessation of GI bleeding in all patients. Conclusions: The prospective incidence of CellCept-associated GI bleeding (8.6% overall) was higher than that reported in prerelease clinical trials (3%) and occurred relatively soon after transplantation (usually 2– 6 months). Distinct endoscopic findings, gastric ulcerated nodules and/or ileocecal valve ulcers, accounted for 14/16 (88%) of all cases. CellCept should be considered a likely and endoscopically identifiable cause of GI bleeding in renal transplant recipients.
277 Turbulent two phase flow; a novel method for cleaning and high grade disinfection of flexible endoscopies and internal channels Stanley Benjamin, MD, Mohamed Labib, Ph.D. Georgetown University and Novaflux Technologies, Washington, DC and Princeton, NJ.
AJG – Vol. 95, No. 9, 2000
One of the major obstacles to high grade disinfection (HGD) of flexible endoscopies is the biofilm layer that forms on the internal channels of flexible endoscopies (FE). Recently introduced, turbulent two phased flow (TTFF), has been shown to eliminate biofilm from the inside of dental tubing and other long tubular channels. Preliminary work has demonstrated the ability of this technology to remove biofilm from endoscope channels. Aim: To determine the ability of TTFF to provide high level disinfection (⬎106 reduction in organisms) to endoscopies and endoscope channels. Methods: Two previously used endoscopes and two endoscope channels were provided by Pentax Precision Instrument Co., Orangeburg, NY). The endoscopes and channels were contaminated with B. subtilis var. niger at a concentration of 107 CFU/scope and channel by an independent laboratory (Nelson Labs, Inc., Salt Lake City, UT). Scopes and channels were processed using two phase flow of air and surfactant/detergent mixture by Novaflux technologies, Inc. (Princeton, NJ) and sent to Nelson Labs for evaluation. Results:
#1 air/water #1 suction/bx #2 air/water #2 suction/bx* control
Cts/initial
Cts/post-TTFF
% reduction
Log reduction
7.0 ⫻ 10 7.0 ⫻ 107 7.0 ⫻ 107 7.0 ⫻ 107 7.0 ⫻ 107
20 43.7 20 436.6 7 ⫻ 107
⬎99.9% ⬎99.9% ⬎99.9% ⬎99.9% 0
6.1 6.2 6.1 5.2 0
7
* post procedure a leak was found in the channel.
Conclusions: 1) At a minimum TTFF can provide mechanical cleansing of endoscopes, eliminating the need for committed staff and reducing the risk of non-compliance; 2) with appropriate design modifications the technology appears to be able to provide HLD; 3) damaged endoscope channels cannot be cleaned/disinfected appropriately.
278 Changing etiology of upper GI bleeding in AIDS patients Faraz F Berjis, Adnan M Khdair*, Irwin M Grosman. Long Island College Hospital, Brooklyn, NY. Purpose: To compare the etiology of upper GI bleeding (UGIB) in AIDS patients during two time intervals and to assess the impact of contemporary HIV therapy on etiology and prognosis. Methods: Retrospective analysis of 50 patients with AIDS as defined by the CDC criteria who presented to a single center with UGIB (hematemesis and/or melena with a positive nasogastric lavage) and were evaluated by upper endoscopy. Group 1 consists of 27 patients evaluated from 1987– 1993 and group 2 consists of 23 patients from 1996 –2000. Results: 12/27 patients in group 1 (44%) had an AIDS related etiology for the UGIB (8 Candida esophagitis, 3 idiopathic esophageal ulcer and 1 with Kaposi’s sarcoma) while only 1 patient from group 2 (4%) had an AIDS related diagnosis (CMV gastric ulcer). The first group had 15 non-AIDS related causes for UGIB (7 gastric ulcer, 5 erosive gastritis, 2 MalloryWeiss tear and 1 duodenal ulcer). The second group had 22 non-AIDS related causes for UGIB as follows: 9 gastric ulcer, 4 erosive esophagitis, 4 erosive gastritis, 2 duodenitis, 2 bleeding esophageal varices, and 1 Mallory-Weiss tear. The 7 day mortality was 11% in the first group compared to 0% in the second group. Conclusions: We observed a changing pattern of etiology for UGIB in our 2 series of patients with AIDS. Our earlier cohort had a high prevalence of AIDS related causes for GI bleeding while our recent patients had bleeding from causes similar to the general hospitalized population. With better therapy of HIV disease the pattern of UGIB in AIDS patients is changing to become similar to their non-HIV infected peers. The study also shows improved short term mortality in these patients and confirms our previous conclusion that UGIB in AIDS is not a terminal event and these patients should be promptly assessed and treated.