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Injection therapy for bleeding gastric leiomyoma
red ring sign was found by chance in a 66-year-old woman by colonoscopy for guaiac-positive stools. In all four cases of this study, indigo carmine spraying3 was very effective in visualizing lymphoid follicles. Consequently, the red ring was foond to be a part of lymphoid hyperplasia. In three of four cases in this study, the red ring sign was observed in the cecum, and this may be the site where the sign appears most frequently. At present, the difference between lymph follicles with and without the red ring sign is unknown. However, we have observed that HLA-DR antigens are expressed on colonic epithelium in a broad area around the lymph follicle, including the lymph follicle with the red ring sign in Crohn's disease, whereas they are rarely expressed in other diseases (Chiba et al., unpublished observations). Further studies will clarify the differences in lymph follicles among intestinal diseases and between lymph follicles with and without the red ring sign. Mitsuro Chiba, Masahiro Iizuka, Michiro Ohtaka, Toshiyuki Kuwabara, Osamu Masamune, Tsuyoshi Mukoujima, Masuo Ito,
MD MD MD MD MD MD MD
First Department of Internal Medicine Akita University School of Medicine and Akita Medical Center Akita, Japan
REFERENCES 1. Kimura M, Miki K, Ichinose M, et al. A new endoscopic finding of inflammatory bowel disease (IBD) [Abstract]. Gastroenterology 1990;98:AI81. 2. Smith MB, Blackstone MO. Colonic lymphoid nodules: another cause of the red ring sign [Letter). Gastrointest Endosc 1991;37:206-8. 3. Tada M, Niki H, Hattori S, et al. Utility of dye scattering method for the observation of the process of ulcerative colitis. Gastroenterol Endosc 1975;17:668-75 (in Jpn with English abstract). 4. Yoshikawa K, Mori K. Aphthoid colitis. Stomach Intest 1976;11:793-801 (in Japanese with English abstract).
This work was supported in part by a grant from the Research Committee for Intractable Intestinal Diseases (Member: Mitsuro Chiba), Ministry of Welfare, Japan.
Biopsy forceps removal of proximally migrated biliary stent To the Editor: We wish to report another endoscopic method for removing a proximally migrated stent where retrieval may not be possible using the Soehendra stent retrieval device (Wilson Cook Inc., Winston-Salem, N. C.). This method is simpler and quicker than that described by Goh et al.! An 83-year-old white woman presented with painless jaundice. Evaluation including an ultrasound revealed a dilated biliary tree. ERCP showed a mass involving the head of the pancreas obstructing the common bile duct, brushings of which were positive for adenocarcinoma. A small sphincterotomy was made and an 11.5 F 7-cm long Cotton-Leung 730
biliary stent was inserted at the time of diagnosis using a therapeutic side-viewing endoscope. Following the procedure the patient did well for 6 weeks when she again presented with jaundice. A repeat ERCP showed that the stent had migrated proximally into the common bile duct. A standard biopsy forceps (FB-19N; Olympus Corporation of America, Lake Success, N. Y.) was passed through the lumen of the stent in the closed position and fluoroscopically could be seen to emerge out the superior aspect of it. At this point the gastrointestinal assistant opened the forceps which was then withdrawn, pulling the captured stent ahead of it. Once the stent was seen to emerge through the ampulla, the forceps was closed and removed, allowing the stent to be snared in the usual fashion. A longer 9-cm stent was inserted without difficulty. I believe this method of stent retrieval is easier than using a basket or snare since the forceps is passed through the lumen of the stent, obviating the need to entrap or grasp it with a snare or basket, which can be time consuming. The biopsy forceps which was used fits easily through a 10 F or 11.5 F prosthesis. Michael N. Eppel, MB, BCh Kaye Duden, RN Rosemary McCown, RN Bryan Memorial Hospital Lincoln, Nebraska
REFERENCE 1. Goh PMY, Sim EKW, Isaac JR. Endoscopic extraction of a proximally migrated Amsterdam-type biliary endoprosthesis. Gastrointest Endosc 1990;36:539-40.
Injection therapy for bleeding gastric leiomyoma To the Editor: Leiomyomas are the most common of the gastric submucosal tumors and the most frequent cause of submucosal tumor bleeding. Larger leiomyomas (diameter >2 cm) are more prone to bleed. Endoscopically, they present as volcano-like lesions because of the ulceration on the top of the mound, in which a clot or an oozing can be seen. Jensen! suggested that in the absence of healing with medical therapy, surgical excision should be recommended. A recent experience at our Endoscopy Unit indicated that, in appropriate conditions, a less invasive approach can be adopted. A 66-year-old woman with severe chronic obstructive pulmonary disease and a known ulcerated gastric leiomyoma (documented by echoendoscopy) was admitted because of hematemesis and melena. She was on a regimen of 250 mg of theophylline twice a day, 10 mg of cisapride three times a day, and 150 mg ofranitidine twice a day. She was acutely ill, dyspneic, pale, and sweating; her heart rate was 120 beats/min, arterial blood pressure 120/80 mm Hg, hemoglobin 7.8 g/dl, arterial pH 7.43, arterial pC0 2 38.8 mm Hg, arterial p02 55.7 mm Hg, and urea 128 mg/dl; a naso-gastric tube aspiration produced red blood, and a rectal examination showed tarry stools. After oxygen and fluid administration was started, an GASTROINTESTINAL ENDOSCOPY
emergency upper gastrointestinal endoscopy was performed, which revealed a large (3.5 em diameter) broad-based polypoid lesion, on the anterior wall of the antrum, ulcerated at the top and actually oozing. The bleeding was stopped by injection of the ulcerated crater with 20 ml of 1:10,000 epinephrine in normal saline and an additional 10 ml of polidocanol 1 % were also injected just inside the crater. There was no re-bleeding and at an endoscopic control 48 hours later the polypoid lesion appeared as a mound with a clean ulcer at the top. Oral feeding was resumed, and therapy with 40 mg of omeprazole daily was started. At an endoscopic control 4 weeks later, the ulcer was completely healed, and tumor diameter was reduced to about 2 em; the treatment was switched to 20 mg of omeprazole daily. At 6 months the patient is well, her hemoglobin level 14.3. gjdl, and the dimensions of the leiomyoma are unchanged without any evidence of surface ulceration. Although the indication for surgical removal of large bleeding gastric leiomyomas remains, our experience shows that, in selected cases, a more conservative management can be appropriate. An endoscopic treatment with sclerosing agents aimed to control the bleeding and to induce a coagulative necrotic shrikage of the muscle core, combined with a potent gastric acid pump inhibitor, proved effective in avoiding surgery in a high surgical risk patient and in reducing the size of the tumor. Walter Giorcelli, MD Marcello Rodi, MD Servizio di Endoscopia digestiva Divisione di Medicina Generale Ospedale S. Andrea Vercelli, Italy
ration pneumonia, resulting in severe obstructive lung disease. She also had childhood polio leaving her with residual neurologic deficits for which she required assistance with ambulation. Clinical examination revealed a frail and tachypneic woman. There was neither jaundice nor stigmata of chronic liver disease. Muscular atrophy of both lower limbs due to polio was noted. The liver function tests showed increased alkaline phosphatase three times above the normal level. Ultrasound of the abdomen showed dilated intra- and extrahepatic ducts. Initial attempts to pass an 8.9-mm forward-viewing gastroscope by mouth were unsuccessful due to the severe pharyngeal stenosis. During these attempts, there was severe oxygen desaturation as monitored with digital oximetry. We therefore elected to gain access to the papilla via the gastrostomy stoma. The gastrostomy tube was removed and the stomal opening was slowly dilated with an Olbat balloon dilator from 20 to 30 F to allow passage of an end-viewing gastroscope, 10 mm in diameter. The gastroscope was introduced with the patient lying in the left lateral decubitus position after very light sedation of 5 mg of intravenous diazepam and 20 mg of buscopan. The gastroscope was passed into the second part of the duodenum and retroflexed to gain access to the papilla. The common bile duct was then cannulated with a standard catheter and a filling defect was identified in a dilated common bile duct (Fig. 1). An 8mm sphincterotomy was carried out with the usual bowshaped papillotome. A basket could then be introduced and a 7-mm stone was extracted. Cannulation and subsequent interventional maneuvers were particularly difficult given
REFERENCES 1. Jensen DM. Benign and malignant tumor of the stomach. In:
Sivak MV, ed. Gastroenterologic endoscopy. Philadelphia: WB Saunders, 1987.
Endoscopic retrograde cholangiography, sphincterotomy, and gallstone extraction via gastrostomy To the Editor: Since the introduction of diagnostic and therapeutic endoscopic retrograde cholangiography, only one report could be found regarding access to the ampulla of Vater and cannulation of the common bile duct via a gastrostomy.! This report describes endoscopic retrograde cholangiography, sphincterotomy, and successful gallstone removal from the common bile duct through an existing gastrostomy following stomal dilation. A 68-year-old woman presented with biliary colic. She required a gastrostomy feeding tube radiologically inserted 1 year previously because of a severe esophageal inlet obstruction resulting from radiation for laryngeal carcinoma 10 years earlier. A complication of this was frequent aspiVOLUME 38, NO.6, 1992
Figure 1. Transgastric cholangiogram showing gallstones in the common bile duct. Note that the endoscope enters the stomach via the abdominal wall and not via the esophagus.
731
MD MD MD MD MD MD MD
First Department of Internal Medicine Akita University School of Medicine and Akita Medical Center Akita, Japan
REFERENCES 1. Kimura M, Miki K, Ichinose M, et al. A new endoscopic finding of inflammatory bowel disease (IBD) [Abstract]. Gastroenterology 1990;98:AI81. 2. Smith MB, Blackstone MO. Colonic lymphoid nodules: another cause of the red ring sign [Letter). Gastrointest Endosc 1991;37:206-8. 3. Tada M, Niki H, Hattori S, et al. Utility of dye scattering method for the observation of the process of ulcerative colitis. Gastroenterol Endosc 1975;17:668-75 (in Jpn with English abstract). 4. Yoshikawa K, Mori K. Aphthoid colitis. Stomach Intest 1976;11:793-801 (in Japanese with English abstract).
This work was supported in part by a grant from the Research Committee for Intractable Intestinal Diseases (Member: Mitsuro Chiba), Ministry of Welfare, Japan.
Biopsy forceps removal of proximally migrated biliary stent To the Editor: We wish to report another endoscopic method for removing a proximally migrated stent where retrieval may not be possible using the Soehendra stent retrieval device (Wilson Cook Inc., Winston-Salem, N. C.). This method is simpler and quicker than that described by Goh et al.! An 83-year-old white woman presented with painless jaundice. Evaluation including an ultrasound revealed a dilated biliary tree. ERCP showed a mass involving the head of the pancreas obstructing the common bile duct, brushings of which were positive for adenocarcinoma. A small sphincterotomy was made and an 11.5 F 7-cm long Cotton-Leung 730
biliary stent was inserted at the time of diagnosis using a therapeutic side-viewing endoscope. Following the procedure the patient did well for 6 weeks when she again presented with jaundice. A repeat ERCP showed that the stent had migrated proximally into the common bile duct. A standard biopsy forceps (FB-19N; Olympus Corporation of America, Lake Success, N. Y.) was passed through the lumen of the stent in the closed position and fluoroscopically could be seen to emerge out the superior aspect of it. At this point the gastrointestinal assistant opened the forceps which was then withdrawn, pulling the captured stent ahead of it. Once the stent was seen to emerge through the ampulla, the forceps was closed and removed, allowing the stent to be snared in the usual fashion. A longer 9-cm stent was inserted without difficulty. I believe this method of stent retrieval is easier than using a basket or snare since the forceps is passed through the lumen of the stent, obviating the need to entrap or grasp it with a snare or basket, which can be time consuming. The biopsy forceps which was used fits easily through a 10 F or 11.5 F prosthesis. Michael N. Eppel, MB, BCh Kaye Duden, RN Rosemary McCown, RN Bryan Memorial Hospital Lincoln, Nebraska
REFERENCE 1. Goh PMY, Sim EKW, Isaac JR. Endoscopic extraction of a proximally migrated Amsterdam-type biliary endoprosthesis. Gastrointest Endosc 1990;36:539-40.
Injection therapy for bleeding gastric leiomyoma To the Editor: Leiomyomas are the most common of the gastric submucosal tumors and the most frequent cause of submucosal tumor bleeding. Larger leiomyomas (diameter >2 cm) are more prone to bleed. Endoscopically, they present as volcano-like lesions because of the ulceration on the top of the mound, in which a clot or an oozing can be seen. Jensen! suggested that in the absence of healing with medical therapy, surgical excision should be recommended. A recent experience at our Endoscopy Unit indicated that, in appropriate conditions, a less invasive approach can be adopted. A 66-year-old woman with severe chronic obstructive pulmonary disease and a known ulcerated gastric leiomyoma (documented by echoendoscopy) was admitted because of hematemesis and melena. She was on a regimen of 250 mg of theophylline twice a day, 10 mg of cisapride three times a day, and 150 mg ofranitidine twice a day. She was acutely ill, dyspneic, pale, and sweating; her heart rate was 120 beats/min, arterial blood pressure 120/80 mm Hg, hemoglobin 7.8 g/dl, arterial pH 7.43, arterial pC0 2 38.8 mm Hg, arterial p02 55.7 mm Hg, and urea 128 mg/dl; a naso-gastric tube aspiration produced red blood, and a rectal examination showed tarry stools. After oxygen and fluid administration was started, an GASTROINTESTINAL ENDOSCOPY
emergency upper gastrointestinal endoscopy was performed, which revealed a large (3.5 em diameter) broad-based polypoid lesion, on the anterior wall of the antrum, ulcerated at the top and actually oozing. The bleeding was stopped by injection of the ulcerated crater with 20 ml of 1:10,000 epinephrine in normal saline and an additional 10 ml of polidocanol 1 % were also injected just inside the crater. There was no re-bleeding and at an endoscopic control 48 hours later the polypoid lesion appeared as a mound with a clean ulcer at the top. Oral feeding was resumed, and therapy with 40 mg of omeprazole daily was started. At an endoscopic control 4 weeks later, the ulcer was completely healed, and tumor diameter was reduced to about 2 em; the treatment was switched to 20 mg of omeprazole daily. At 6 months the patient is well, her hemoglobin level 14.3. gjdl, and the dimensions of the leiomyoma are unchanged without any evidence of surface ulceration. Although the indication for surgical removal of large bleeding gastric leiomyomas remains, our experience shows that, in selected cases, a more conservative management can be appropriate. An endoscopic treatment with sclerosing agents aimed to control the bleeding and to induce a coagulative necrotic shrikage of the muscle core, combined with a potent gastric acid pump inhibitor, proved effective in avoiding surgery in a high surgical risk patient and in reducing the size of the tumor. Walter Giorcelli, MD Marcello Rodi, MD Servizio di Endoscopia digestiva Divisione di Medicina Generale Ospedale S. Andrea Vercelli, Italy
ration pneumonia, resulting in severe obstructive lung disease. She also had childhood polio leaving her with residual neurologic deficits for which she required assistance with ambulation. Clinical examination revealed a frail and tachypneic woman. There was neither jaundice nor stigmata of chronic liver disease. Muscular atrophy of both lower limbs due to polio was noted. The liver function tests showed increased alkaline phosphatase three times above the normal level. Ultrasound of the abdomen showed dilated intra- and extrahepatic ducts. Initial attempts to pass an 8.9-mm forward-viewing gastroscope by mouth were unsuccessful due to the severe pharyngeal stenosis. During these attempts, there was severe oxygen desaturation as monitored with digital oximetry. We therefore elected to gain access to the papilla via the gastrostomy stoma. The gastrostomy tube was removed and the stomal opening was slowly dilated with an Olbat balloon dilator from 20 to 30 F to allow passage of an end-viewing gastroscope, 10 mm in diameter. The gastroscope was introduced with the patient lying in the left lateral decubitus position after very light sedation of 5 mg of intravenous diazepam and 20 mg of buscopan. The gastroscope was passed into the second part of the duodenum and retroflexed to gain access to the papilla. The common bile duct was then cannulated with a standard catheter and a filling defect was identified in a dilated common bile duct (Fig. 1). An 8mm sphincterotomy was carried out with the usual bowshaped papillotome. A basket could then be introduced and a 7-mm stone was extracted. Cannulation and subsequent interventional maneuvers were particularly difficult given
REFERENCES 1. Jensen DM. Benign and malignant tumor of the stomach. In:
Sivak MV, ed. Gastroenterologic endoscopy. Philadelphia: WB Saunders, 1987.
Endoscopic retrograde cholangiography, sphincterotomy, and gallstone extraction via gastrostomy To the Editor: Since the introduction of diagnostic and therapeutic endoscopic retrograde cholangiography, only one report could be found regarding access to the ampulla of Vater and cannulation of the common bile duct via a gastrostomy.! This report describes endoscopic retrograde cholangiography, sphincterotomy, and successful gallstone removal from the common bile duct through an existing gastrostomy following stomal dilation. A 68-year-old woman presented with biliary colic. She required a gastrostomy feeding tube radiologically inserted 1 year previously because of a severe esophageal inlet obstruction resulting from radiation for laryngeal carcinoma 10 years earlier. A complication of this was frequent aspiVOLUME 38, NO.6, 1992
Figure 1. Transgastric cholangiogram showing gallstones in the common bile duct. Note that the endoscope enters the stomach via the abdominal wall and not via the esophagus.
731