Figure 3 Eckart Frimberger, MD II. Medizinische Klinik und Poliklinik Klinikum rechts der Isar MOnchen, West Germany
REFERENCE 1. Stiegmann G, Cambre T, Sun JH. A new endoscopic elastic band ligating device. Gastrointest Endosc 1986;32:230-3.
Benign ulcers of the colon To the Editor: The article on benign ulcers of the colon by Shah et al.,l as well as an earlier one,2 omitted one subset of patients that from our review of the literature seems prone to this condition. Up until 1982,3 12 cases of ulcers of the colon had been described in chronic renal failure. Six of the 12 cases occurred in transplanted patients. Endoscopists should be aware of this relationship.
(normal 20 to 70). Upper gastrointestinal series showed mild gastroesophageal reflux. Abdominal ultrasound was said to show a benign-appearing hepatic cyst. Oral cholycystogram was normal. Her symptoms recurred 14 months later and her bilirubin was 4.3 mg/dl, alkaline phosphatase 608 units/liter, SGOT 117 units/liter (normal 9 to 50), GGT 709 units/liter. Gastroscopy was normal. ERCP was performed which showed two large filling defects within the common bile duct which were smooth but irregular (Fig. 1). The mass was felt to be too large to remove by endoscopic means. At exploratory laparotomy, a viable 8 -cm tumor embolus encased in bile was removed from the common bile duct. Liver metastases from an adenocarcinoma of unknown primary were noted at the time. The differential diagnosis of an intraluminal mass in the biliary system includes stones, blood clots, and benign and malignant tumors. Diagnosis of intraluminal tumors has been made by intraoperative cholangiograms,!,2 percutaneous transhepatic cholangiography (PTC),3 and now ERCP. Hepatocellular carcinoma,2,4 melanoma,5,6 colon carcinoma,!,3,7 cholangiocarcinoma,! and cavernous hemangioma! have all been reported as sources of tumor emboli in the biliary system. Jaundice is usually an ominous sign in patients with cancer, but this subset of patients can benefit
Gerald L. Posner, MD Stephen Strohlein, MD Division of Gastroenterology Interfaith Medical Center Brooklyn, New York
REFERENCES 1. Shah NC, Ostrov AH, Cavallero JB, Rodgers JB. Benign ulcers of the colon. Gastrointest Endosc 1986;32:102-4. 2. Kurtz MD. Colonoscopic diagnosis of nonspecific ulcer of the colon. Gastrointest Endosc 1976;23:90-1. 3. Huded FV, Posner GL, Tick R. Nonspecific ulcer of the colon in a chronic hemodialysis patient. Am J Gastroenterol 1982;77:913-6.
Intrabiliary tumor embolus: demonstration by ERCP To the Editor: Free-floating tumor masses within the biliary system have recently been recognized as a cause of intermittent biliary obstruction.! A case is presented in which the diagnosis was made by endoscopic retrograde cholangiopancreatography (ERCP). A 75-year-old woman was in good health until September 1983 when she had a I-week history of fatigue and sweating. This resolved spontaneously after an acute episode of lancinating epigastric pain. Liver function studies were normal except ')'-glutamyl transferase (GGT) of 160 units/liter (normal, 14 to 68) and alkaline phosphatase of 79 units/liter 130
Figure 1. ERCP showing irregular large filling defects (arrows) within the common bile duct.
GASTROINTESTINAL ENDOSCOPY
from intervention because the obstruction in these cases can be easily removed and the patients' status will improve. Survival can be surprisingly long after diagnosis of a tumor embolus. Our patient is alive 17 months after ERCP. Roslyn et al.' reported a patient with a 40-month survival, and Levine et al.? reported a patient alive 15 years after the diagnosis of liver metastases and 30 months after probable tumor emboli were removed. Biliary emboli from hepatocellular carcinoma do not carry the same prognosis since Kojiro et al. 2 reported 24 cases of bile duct tumor growths with a median survival of only 16 days. Richard M. Auld, MD Joseph B. Weiss, MD Department of Gastroenterology Scripps Clinic and Research Foundation La Jolla, California
REFERENCES 1. Roslyn JJ, Kuchenbecker S, Longmire WP, Tompkins RK. Floating tumor debris: a cause of intermittent biliary obstruction. Arch Surg 1984;119:1312-5. 2. Kojiro M, Kawabata K, Kawano Y, Shirai F, Takemoto N, Nakashima T. Hepatocellular carcinoma presenting as intrabile duct tumor growth: a clinicopathologic study of24 cases. Cancer 1982;49:2144-7. 3. Gray RR, Mackenzie RL, Alan KP. Cholangiographic demonstration of carcinoma of the colon metastatic to the lumen of the common bile duct. Gastrointest Radiol 1982;7:71-2. 4. Tsuzuki T, Ogata Y, lida S, Kasajima M, Takahashi S. Hepatoma with obstructive jaundice due to the migration of a tumor mass in the biliary tract: report of a successful resection. Surgery 1979;85:593-8. 5. Daunt N, King OM. Metastatic melanoma in the biliary tree. Br J Radiol 1982;55:873-4. 6. McArthur MS, Teergarden OK. Metastatic melanoma presenting as obstructive jaundice with hemobilia. Am J Surg 1983;145:830-2. 7. Levine AW, Donegan WL, Irwin M. Adenocarcinoma of the colon with hepatic metastases: fifteen year survival. Jl\.MA 1982;247(20):2809-10.
Contributions in digestive endoscopy in Europe To the Editor: In a recent issue of Gastrointestinal Endoscopy,' Dr. Cotton reviewed published contributions in digestive endoscopy in Europe, analyzing the characteristics of several journals. As coordinator of the Italian Journal of Digestive Endoscopy (Giornale Italiano di Endoscopia Digestiva), I regret that Dr. Cotton forgot our journal, which began regular publication in 1976. The primary language is Italian, but every article is abstracted in English. The journal has a particular connection with Endoscopy (journal of the European Society of Gastrointestinal Endoscopy) publishing the text of "European News," as well as with Gastroenterological Endoscopy of Japan. I will be very grateful if you will make your readers aware of our journal, which is a very important resource for endoscopists.
R. Cheli, MD Genova, Italy
VOLUME 33, NO. 2, 1987
REFERENCE 1. Cotton PB. Survey of recent European literature. Gastrointest Endosc 1986;32:310--2.
A gastrointestinal endoscopy service in Greece To the Editor: Greece is a developing country with a population of about 10 million. Upper gastrointestinal endoscopy using flexible fiberoptic instruments was introduced in Greece in 1970. However, over the years there has been no information about present facilities and future requirements. In 1984, 39 questionnaires were mailed to all known gastrointestinal endoscopy units (GEUs) in community or university hospitals. Thirty-four GEUs (87%) returned the questionnaire. Sixty-three percent of these were in the capital (Athens) and 50% were attached to university departments of internal medicine. There were 109 physicians working in these GEUs including consultants (24%), registrars (50%), and trainees in gastroenterology (26%). The latter spend a 4-year period training in gastroenterology before taking oral examinations for their membership. Similarly to the ASGE membership survey,' gastroenterology was the primary specialty of 82% of the endoscopists and general surgery was second in frequency (16%) as a primary specialty. Gastrointestinal endoscopy in Greece is provided free of charge through the National Health Service. About 40% of the diagnostic endoscopies are performed on an outpatient basis and consent of the patient for the examination is verbal. In community hospitals which have a GEU, surgeons refer their patients for endoscopic diagnosis before operating on them. However, many general practitioners working in small cities still consider endoscopy as something akin to a surgical procedure. The number of upper gastrointestinal endoscopies and colonoscopies performed per GEU during 1983 in comparison to that in a British survey2 is shown in Figure 1. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in only three GEUs, including our own, and endoscopic polypectomy in 31 % of them. There were few GEUs providing services for laparoscopy, injection sclerotherapy for esophageal varices, and dilation of peptic esophageal strictures. Endoscopic sphincterotomy was not performed in any of the GEUs at the time of the survey. Olympus (59%), Fujinon (23%), and ACMI (18%) were the manufacturers supplying fiberoptic instruments to Greece. Almost half (44%) of the GEUs had only one gastroscope, although there were GEUs with up to three gastroscopes. Fifty-two percent of the GEUs had two or three colonoscopes or flexible sigmoidoscopes, but the remainder had only one. Only 33% of the GEUs had an electrosurgical unit for transfiber-optic procedures. Twentyfour percent of the fiberscopes were purchased after 1980. Contrary to an Italian survey3 in which many unused instruments were identified, in our survey there was much concern about a shortage of funds for new endoscopes (a gastroscope costs about 12,000 US$ in Greece) and many complaints about unsatisfactory repair facilities. The Greek Society of Gastroenterology (GSG) was 131