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Eye protection during sclerotherapy
Subconjunctival or palpebral hemorrhage has never been mentioned as a specific complication of gastroscopy, but may have been overlooked, ignored, or lumped in the miscellaneous category of reported instances. Such hemorrhages can occur spontaneously but often are precipitated by maneuvers that increase the intrathoracic pressure, such as coughing, retching, or straining. These increase intravascular pressure, which can rupture delicate subconjunctival vessels. We report this innocent complication which can be distressing to the patient, embarassing to the physician, and give endoscopy a black eye. Such an untoward event might be considered a variant of the sclerotherapist's eye. 3
Once the known predisposing conditions are excluded, it is important to reassure the startled patient and the equally alarmed endoscopist of the harmless nature of this entity and its subsequent uneventful resolution. Dean Pappas, Jose Romeu, Julio Messer, Pradyuman B. Dave,
Department of Medicine Mount Sinai Services-City Hospital Center Elmhurst, New York Mount Sinai School of Medicine New York, New York
I. S. Pomeranz, MD E. A. Shaffer, MD University of Calgary Calgary, Alberta, Canada
REFERENCES 1. Cotton PB, Williams CB. Upper gastrointestinal endoscopy. In:
Practical gastrointestinal endoscopy, 2nd ed. Edinburgh: Blackwell, 1982:44-6. 2. Silvis SE, Nebel 0, Rogers G, Sugawa C, Mandelstam P. Endoscopic complications. Results of the 1974 ASGE survey. JAMA 1976;235:928-30. 3. Herlihy KJ, Bozymski EM. Sclerotherapist's eye (letter). Gastrointest Endosc 1982;24:42-3.
Postendoscopy subconjunctival hemorrhage To the Editor: We recently gastroscoped a 32-year-old white woman with a several days' history of aminosalicylic acid ingestion and intermittent dysphagia for solids and liquids. She was premedicated with meperidine and diazepam and the procedure was completed without difficulty, although minimal gagging was noted during introduction of the instrument. Esophagogastroduodenoscopy (EGD) revealed several antral erosions. Shortly after endoscopy, the patient developed bilateral subconjunctival hemorrhage and diffuse petechiae over the face and neck. Platelet count, prothrombin time, bleeding time, and Rumpel-Leede test were normal. The clinical signs resolved within 10 days. Subconjunctival hemorrhages result from rupture of small blood vessels beneath the conjunctiva and may be related to certain predisposing conditions (trauma, hypertension, blood dyscrasias) and a variety of systemic diseases (diabetes mellitus, Fabry's disease, cryglobulinemia, amyloidosis).! More commonly, they appear spontaneously without apparent cause except for a history of coughing, vomiting, or exertion. Postproctoscopic periorbital purpura has been described in a patient with amyloidosis, 2 but, to our knowledge, purpura, petechiae, and subconjunctival hemorrhage have not been described following EGD. Our patient has none of the known predisposing conditions. We therefore speculate that even mild gagging or Valsalva during EGD may have been the causative factor. This benign condition has not been included in any of several major reviews of endoscopic complications. 3- 5 VOLUME 30, NO.6, 1984
MD MD MD MD
REFERENCES 1. Newell FW. Ophthalmology, principles and concepts, 5th ed.
St. Louis, Mo.: CV Mosby Co., 1982:187. 2. Kyle RA, Bayrd ED. Amyloidosis: review of 236 cases. Medicine 1975;54:271-95. 3. Gilbert DA, Silverstein FE, Tedesco FJ. National ASGE survey on upper gastrointestinal bleeding, complications of endoscopy. Dig Dis Sci 1981;27:94-102. 4. Davis RE, Graham DY. Endoscopic complications, the Texas experience. Gastrointest Endosc 1979;25:148-49. 5. Silvis SE, Nebel 0, Rogers G, Sugawa C, Mandelstam P. Endoscopic complications. JAMA 1976;235:928-30.
Eye protection during sclerotherapy To the Editor: Esophageal sclerotherapy is becoming increasingly useful and popular as a therapeutic technique for variceal hemorrhage. Many of us, however, are concerned about the ophthalmotoxicity of sodium morrhuate. We therefore suggest that physicians and personnel involved in sclerotherapy sessions use some protective eye covering. The usual protective eye coverings that are available detract from the endoscopic image. We have modified the conventional plastic eye shield so that only the right eye is protected (Fig. 1). As the risk of eye injury comes mostly from the right, this should
Figure 1. Norton Industries protective eye lens with left half of lens broken off and right half of lens in place. 375
provide a significant margin of safety while allowing a clear endoscopic view. Martin S. Kleinman, MD Ellen Coyne Delois Smith University of Rochester School of Medicine and Dentistry Strong Memorial Hospital Rochester, New York
chik prosthesis. Ann Surg 1982;195:686-90. 4. Phelps JE, Sanowski RP, Kozarek RA, Fredell CH. Assessment of a prosthetic device for correction of esophageal reflux. Gastroenterology 1981;80:1252.
Temporary stenting as an aid to esophageal dilation To the Editor:
Endoscopic appearance of an Angelchik prosthesis To the Editor: We wish to report an unusual endoscopic view of an Angelchik prosthesis and to alert all endoscopists and surgeons to be aware of this complication of the device. A 65-year-old woman presented to the hospital with the chief complaint of dysphagia, epigastric pain, left upper quadrant pain, and fever. The patient had been diagnosed as having polymyalgia approximately 10 months prior to her admission. The patient dated her muscle pain, malaise, fever, shoulder pain, and nausea to the time of her hiatal hernia repair, which was done by inserting an Angelchik prosthesis. The patient was treated with varying doses of prednisone with some improvement in her muscle pain and malaise. An upper gastrointestinal series showed deformity of the upper stomach. There was a pouch-like deformity which on retroflex view of the upper portion of the stomach contained gelatinous material. Because of a fall in hematocrit and continued epigastric pain, a repeat endoscopy was done, and it appeared that a perforation of her stomach by the Angelchik prosthesis had occurred. At the time of surgery, the patient was found to have a walled-off abscess and perforation of the stomach by the Angelchik prosthesis. The Angelchik prosthesis has been described and used widely since 1973. 1 It is estimated that approximately 3500 devices have been placed in this country.2 Although gastropericardiaI and pericardial abscesses have been reported with the Nissen fundoplication,3 we are unaware of abscess being described with the Angelchik prosthesis. Erosion of the Angelchik device into the stomach and into the esophagus, however, has been reported. 4 We recognized the Angelchik prosthesis at the repeat endoscopy because of the persistence of the "gelatinous mass." Endoscopists need to be alert to this presentation of the Angelchik prosthesis.
Esophageal dilation affords an alternative to surgery in the management of benign' or malignane esophageal strictures. Use of a spring-tipped wire to guide the dilators may be necessary or may facilitate dilation in patients with a dilated or tortuous esophagus or with strictures that are narrow, acutely angulated, or with irregular contours and/ or overhanging edges. 3 It may also make dilation less hazardous, especially if eso~hageal ulcerations or diverticula are present. However, it is in these patients that guide wire passage is most difficult. Frequently several sessions of wireguided dilation are required before dysphagia is relieved. Passage can be facilitated by use of endoscopic guidance,4 but repeated endoscopy for wire placement is time consuming and costly. We describe a technique which allows rapid repeat placement of a guide wire for esophageal dilation. An 80-year-old man who was able to swallow only small amounts of liquid, presented with a 4-month history of progressive dysphagia. A barium swallow (Fig. 1) showed tertiary contractions and a very narrow distal esophageal stricture with an adjacent diverticulum. Endoscopy confirmed these findings and biopsies revealed acute inflammation. It was elected to treat the stricture nonsurgically, and Eder-Puestow dilators were initially required. With
W. Roger Carlisle, MD David A. Mclain, MD Birmingham, Alabama
REFERENCES 1. Angelchik J-P. A new surgical procedure for the treatment of
gastroesophageal reflux and hiatal hernia. Surg Gynecol Obstet 1979;148:246-8. 2. Ikard RW, Jacobs JK. Gastropericardial fistula and pericardial abscess: unusual complications of subphrenic abscess following Nissen fundoplication. South Med J 1974;67:17-9. 3. Starling JR, Reichelderfer MO, Pellett JR, Belzer FO. Treatment of symptomatic gastroesophageal reflux using the Angel376
Figure 1. Barium swallow revealing tertiary contractions above a narrow stricture with a periampullary diverticulum (arrow). GASTROINTESTINAL ENDOSCOPY
Once the known predisposing conditions are excluded, it is important to reassure the startled patient and the equally alarmed endoscopist of the harmless nature of this entity and its subsequent uneventful resolution. Dean Pappas, Jose Romeu, Julio Messer, Pradyuman B. Dave,
Department of Medicine Mount Sinai Services-City Hospital Center Elmhurst, New York Mount Sinai School of Medicine New York, New York
I. S. Pomeranz, MD E. A. Shaffer, MD University of Calgary Calgary, Alberta, Canada
REFERENCES 1. Cotton PB, Williams CB. Upper gastrointestinal endoscopy. In:
Practical gastrointestinal endoscopy, 2nd ed. Edinburgh: Blackwell, 1982:44-6. 2. Silvis SE, Nebel 0, Rogers G, Sugawa C, Mandelstam P. Endoscopic complications. Results of the 1974 ASGE survey. JAMA 1976;235:928-30. 3. Herlihy KJ, Bozymski EM. Sclerotherapist's eye (letter). Gastrointest Endosc 1982;24:42-3.
Postendoscopy subconjunctival hemorrhage To the Editor: We recently gastroscoped a 32-year-old white woman with a several days' history of aminosalicylic acid ingestion and intermittent dysphagia for solids and liquids. She was premedicated with meperidine and diazepam and the procedure was completed without difficulty, although minimal gagging was noted during introduction of the instrument. Esophagogastroduodenoscopy (EGD) revealed several antral erosions. Shortly after endoscopy, the patient developed bilateral subconjunctival hemorrhage and diffuse petechiae over the face and neck. Platelet count, prothrombin time, bleeding time, and Rumpel-Leede test were normal. The clinical signs resolved within 10 days. Subconjunctival hemorrhages result from rupture of small blood vessels beneath the conjunctiva and may be related to certain predisposing conditions (trauma, hypertension, blood dyscrasias) and a variety of systemic diseases (diabetes mellitus, Fabry's disease, cryglobulinemia, amyloidosis).! More commonly, they appear spontaneously without apparent cause except for a history of coughing, vomiting, or exertion. Postproctoscopic periorbital purpura has been described in a patient with amyloidosis, 2 but, to our knowledge, purpura, petechiae, and subconjunctival hemorrhage have not been described following EGD. Our patient has none of the known predisposing conditions. We therefore speculate that even mild gagging or Valsalva during EGD may have been the causative factor. This benign condition has not been included in any of several major reviews of endoscopic complications. 3- 5 VOLUME 30, NO.6, 1984
MD MD MD MD
REFERENCES 1. Newell FW. Ophthalmology, principles and concepts, 5th ed.
St. Louis, Mo.: CV Mosby Co., 1982:187. 2. Kyle RA, Bayrd ED. Amyloidosis: review of 236 cases. Medicine 1975;54:271-95. 3. Gilbert DA, Silverstein FE, Tedesco FJ. National ASGE survey on upper gastrointestinal bleeding, complications of endoscopy. Dig Dis Sci 1981;27:94-102. 4. Davis RE, Graham DY. Endoscopic complications, the Texas experience. Gastrointest Endosc 1979;25:148-49. 5. Silvis SE, Nebel 0, Rogers G, Sugawa C, Mandelstam P. Endoscopic complications. JAMA 1976;235:928-30.
Eye protection during sclerotherapy To the Editor: Esophageal sclerotherapy is becoming increasingly useful and popular as a therapeutic technique for variceal hemorrhage. Many of us, however, are concerned about the ophthalmotoxicity of sodium morrhuate. We therefore suggest that physicians and personnel involved in sclerotherapy sessions use some protective eye covering. The usual protective eye coverings that are available detract from the endoscopic image. We have modified the conventional plastic eye shield so that only the right eye is protected (Fig. 1). As the risk of eye injury comes mostly from the right, this should
Figure 1. Norton Industries protective eye lens with left half of lens broken off and right half of lens in place. 375
provide a significant margin of safety while allowing a clear endoscopic view. Martin S. Kleinman, MD Ellen Coyne Delois Smith University of Rochester School of Medicine and Dentistry Strong Memorial Hospital Rochester, New York
chik prosthesis. Ann Surg 1982;195:686-90. 4. Phelps JE, Sanowski RP, Kozarek RA, Fredell CH. Assessment of a prosthetic device for correction of esophageal reflux. Gastroenterology 1981;80:1252.
Temporary stenting as an aid to esophageal dilation To the Editor:
Endoscopic appearance of an Angelchik prosthesis To the Editor: We wish to report an unusual endoscopic view of an Angelchik prosthesis and to alert all endoscopists and surgeons to be aware of this complication of the device. A 65-year-old woman presented to the hospital with the chief complaint of dysphagia, epigastric pain, left upper quadrant pain, and fever. The patient had been diagnosed as having polymyalgia approximately 10 months prior to her admission. The patient dated her muscle pain, malaise, fever, shoulder pain, and nausea to the time of her hiatal hernia repair, which was done by inserting an Angelchik prosthesis. The patient was treated with varying doses of prednisone with some improvement in her muscle pain and malaise. An upper gastrointestinal series showed deformity of the upper stomach. There was a pouch-like deformity which on retroflex view of the upper portion of the stomach contained gelatinous material. Because of a fall in hematocrit and continued epigastric pain, a repeat endoscopy was done, and it appeared that a perforation of her stomach by the Angelchik prosthesis had occurred. At the time of surgery, the patient was found to have a walled-off abscess and perforation of the stomach by the Angelchik prosthesis. The Angelchik prosthesis has been described and used widely since 1973. 1 It is estimated that approximately 3500 devices have been placed in this country.2 Although gastropericardiaI and pericardial abscesses have been reported with the Nissen fundoplication,3 we are unaware of abscess being described with the Angelchik prosthesis. Erosion of the Angelchik device into the stomach and into the esophagus, however, has been reported. 4 We recognized the Angelchik prosthesis at the repeat endoscopy because of the persistence of the "gelatinous mass." Endoscopists need to be alert to this presentation of the Angelchik prosthesis.
Esophageal dilation affords an alternative to surgery in the management of benign' or malignane esophageal strictures. Use of a spring-tipped wire to guide the dilators may be necessary or may facilitate dilation in patients with a dilated or tortuous esophagus or with strictures that are narrow, acutely angulated, or with irregular contours and/ or overhanging edges. 3 It may also make dilation less hazardous, especially if eso~hageal ulcerations or diverticula are present. However, it is in these patients that guide wire passage is most difficult. Frequently several sessions of wireguided dilation are required before dysphagia is relieved. Passage can be facilitated by use of endoscopic guidance,4 but repeated endoscopy for wire placement is time consuming and costly. We describe a technique which allows rapid repeat placement of a guide wire for esophageal dilation. An 80-year-old man who was able to swallow only small amounts of liquid, presented with a 4-month history of progressive dysphagia. A barium swallow (Fig. 1) showed tertiary contractions and a very narrow distal esophageal stricture with an adjacent diverticulum. Endoscopy confirmed these findings and biopsies revealed acute inflammation. It was elected to treat the stricture nonsurgically, and Eder-Puestow dilators were initially required. With
W. Roger Carlisle, MD David A. Mclain, MD Birmingham, Alabama
REFERENCES 1. Angelchik J-P. A new surgical procedure for the treatment of
gastroesophageal reflux and hiatal hernia. Surg Gynecol Obstet 1979;148:246-8. 2. Ikard RW, Jacobs JK. Gastropericardial fistula and pericardial abscess: unusual complications of subphrenic abscess following Nissen fundoplication. South Med J 1974;67:17-9. 3. Starling JR, Reichelderfer MO, Pellett JR, Belzer FO. Treatment of symptomatic gastroesophageal reflux using the Angel376
Figure 1. Barium swallow revealing tertiary contractions above a narrow stricture with a periampullary diverticulum (arrow). GASTROINTESTINAL ENDOSCOPY