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Placement of nasojejunal feeding tubes: an alternate technique
S288
Abstracts
rable age with liver cirrhoses and bleeding varices subjected to endoscopic variceal sclerotherapy as a control. 3–On the second day after ligation or sclerotherapy both groups subjected to Doppler study using device of 3.5 Mhz (Hetachi 415) and measurement of portal vein haemodynamic parameters (cross sectional area and velocity). 4 – Congestion index was calculated as follow: Cross sectional area divided by Velocity (cm/second) Results: By comparing portal vein haemodynamic parameters in both groups together, endoscopic variceal ligation showed: 1–Insignificant increase in the portal vein cross sectional area mean⫾SD 0.98⫾0.1 (cm2) versus 0.95⫾0.20 respectively P⫽0.6978 2–Insignificant decrease in the portal vein velocity mean⫾SD 10.5⫾1.5 versus 11.1⫾1.9 (cm/sec) respectively P⫽0.478 3–Significant increase in congestion index (cm/sec) mean⫾SD 0.11⫾0.02 versus 0.09⫾0.01 respectively P⫽0.0277 Conclusions: Endoscopic variceal ligation leads to significant increase in the portal vein congestion index more rapidly than sclerotherapy so I recommend the use of drugs that reduce portal pressure before and after the ligation setting, further study including large number of cases may be needed.
876 THE IMPACT OF SEDATION VS. NO SEDATION IN THE PERFORMANCE OF SUCCESSFUL GASTROSCOPY AMONG ANXIOUS PATIENTS: A DOUBLE BLIND PROSPECTIVE RCT Neena S. Abraham, M.D.*, Kara Thompson, M.Sc., Daniel Woo, M.D., Carlo Fallone, M.D., Serge Mayrand, M.D. and Alan N. Barkun, M.D. Division of Gastroenterology & Department of Medicine, Queen Elizabeth II Health Science Centre–Dalhousie University, Halifax, Nova Scotia, Canada and Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada. Purpose: The current literature suggests that parenteral sedation is required to ensure a successful gastroscopy among those patients who exhibit clinically significant pre–procedural anxiety. Yet, no studies have formally studied this subset of patients in a blinded placebo controlled trial. Methods: A prospective randomized controlled double blind trial assigned patients to undergo gastroscopy with the use of standard parenteral sedation vs. placebo. The primary outcome was “successful endoscopy”–– a composite score of the physician’s rating of technical adequacy (1⫽totally inadequate to 4⫽ totally adequate) and the patient’s satisfaction with their level of comfort (1⫽acceptable to 5⫽unacceptable). A planned secondary outcome was the subgroup analysis of those patients with a clinically relevant mood disorder when screened using a validated instrument, the Hospital Anxiety and Depression Scale (HADS). Possible confounders were considered including demographics (age, gender, race, education), prior experience with gastroscopy, expectations and procedural indication. Univariate and multivariate analysis were completed. Results: 420 patients were randomized (N⫽210 active vs. N⫽210 placebo). Groups were similar for all baseline characteristics. The mean age was 54.5 yrs (SD: 16.1), 52% were female, and 63% of gastroscopies performed were “successful”. 45%of patients described themselves as anxious, however, only 13% had evidence of anxiety when screened by HADS. Among those patients with anxiety, successful endoscopy was five times greater when sedated (95% CI: 1.4 –18.7). Among those without anxiety, successful endoscopy was 8.5 times greater when sedated (95%CI: 5.1–14.2). In both univariate and multivariate analysis, the existence of an anxiety disorder did not exert a differential effect on the occurrence of a successful endoscopy, regardless of randomization group. The best predictor of a successful endoscopy, among all patients, was randomization to sedation (OR⫽8.5; 95%CI: 5.1–14.2). Conclusions: The presence of significant pre–procedural anxiety should not be the rationale to sedate a patient prior to diagnostic gastroscopy. The use of sedation improves the odds of a successful endoscopy among all patients.
AJG – Vol. 97, No. 9, Suppl., 2002
877 ENDOSCOPIC PYLORIC BALLOON DILATATION IN PEDIATRIC PATIENTS WITH DELAYED GASTRIC EMPTYING Nick Ogunmola, M.D.,D.C.H.(UK), Marsha Kay, M.D.*, Robert Wyllie, M.D.,FACG and Vera Hupertz, M.D. Pediatric Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH. Purpose: To determine the outcome of endoscopic pyloric balloon dilatation in pediatric patients with delayed gastric emptying at our institution. We sought to determine the rate of success of the procedure and if there were patient characteristics or technical aspects of the procedure that influenced the procedure outcome. Methods: We performed a retrospective chart review of 18 pediatric patients who underwent endoscopic pyloric balloon dilatation at our institution between January 2000 – May 2002. Serial balloon dilation was performed across the pylorus with controlled radial diameter through the scope (TTS) balloons under direct endoscopic visualization.We reviewed each patients symptoms and physical findings, results of gastric emptying tests, serologic evidence of recent viral illnesses, biopsy findings at the time of endoscopy, number of dilatation procedures, technique of dilatation and outcome following the procedure including repeat gastric emptying studies if available. Results: There were 8 boys and 10 girls with a mean age of 13.7 years. The patients were followed up for a mean of 17 weeks. The mean duration of symptoms prior to the first balloon dilation was 23.9 months. 17% had viral syndromes or serology suggestive of a viral illness prior to onset of their symptoms. The indications for the procedure were delayed gastric emptying due to idiopathic causes (33%), Crohns disease (6%), cyclical vomiting (6%), and GERD (55%). 15 of 18 patients had a gastric emptying test prior to the procedure. 93% of patients had an abnormal gastric emptying time for liquids or solids. 39% of patients had more than one dilatation procedure. The mean number of dilatation procedures per patient was 1.5, with a mean inflation pressure of 59 psi. The mean duration of each inflation was 87.6 sec and the mean number of inflations at each procedure was 3.2. Follow– up was available for 15 patients. No complications were seen in any patients. Resolution of symptoms was seen in 27% and improvement of symptoms was seen in an additional 53% of patients. Conclusions: Endoscopic pyloric balloon dilation with TTS balloons is a safe, minimally invasive procedure with an excellent outcome in pediatric patients with many different types of gastric outlet obstruction.This technique may be especially well suited to children who develop a transient post viral gastroparesis with severe symptoms as an alternative to pyloromyotomy. 878 PLACEMENT OF NASOJEJUNAL FEEDING TUBES: AN ALTERNATE TECHNIQUE J. David Bohler, M.D., Mark Delegge, M.D.* and John Fang, M.D. Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC and University of Utah, UT. Purpose: The use of nasojejunal tube for short–term nutritional support is well established. Proper placement of the NJ tube beyond the Ligament of Treitz can be cumbersome secondary to technical difficulties. This results in many endoscopists avoiding the procedure. We offer an alternate technique that is safe and effective. Methods: A retrospective review of 25 patients with nasojejunal feeding tubes placed with the “push technique” was performed from 1/00 to 12/01. This technique is described as follows: first perform upper endoscopy, taking a 12–french nasoenteric tube and placing a 0.52 and 0.35 guidewire inside the tube, but not to the end, to stiffen the tube. Advance the tube with the guidewires through the nare into the stomach. Observe the tube with the endoscope as it is pushed forward by the nurse or assistant through the pylorus into the distal duodenum or jejunum. If the tube tip engages a mucosal fold, a forcep passed through the biopsy channel is used to reposition the tip for advancement.
AJG – September, Suppl., 2002
Results: 25 cases were selected for analysis. 14 were females, mean age was 52.8 years (range 25–78 years). These tubes were used for feeding a mean time of 10.8 days (range 0 –51 days). The procedure time for tube placement was a mean of 13 minutes (range 3–31 minutes) and success was 100% with no associated complications. One patient (4%) developed an occlusion secondary to kinking which was repositioned and used. Five patients (20%) were discharged to home with tubes in place and being used for nutritional support. Nasoenteric tube use was discontinued secondary to resolution of primary indication in 6 (24%), patient intolerance or accidental displacement in 6 (24%), more permanent access (PEG, PEG/J, or PEJ) in 7 (28%), death from primary disease process in 1 (4%) and unknown in 5 (20%). Conclusions: The new push technique for placement of nasojejunal feeding tubes is safe, reproducible, and effective for short–term nutritional support in those patients unable to tolerate gastric enteral nutrition.
879 HETASTARCH AS AN ALTERNATIVE TO SALINE INJECTION FOR ENDOSCOPIC MUCOSAL RESECTION Tony E. Yusuf, M.D., Ijaz Ahmed, M.B.B.S., Doug Brining, D.V.M. and Gottumukkala S. Raju, M.D., FACG*. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Purpose: Submucosal saline injection is widely used to prevent perforation during endoscopic mucosal resection (EMR). However, quick dissipation of saline not only makes EMR difficult, but also increase the risk of perforation from entrapment of muscle in the snare after the loss of submucosal cushion effect. Submucosal cushion effect from a colloid may last longer as colloids tend to get reabsorped slowly compared to crystalloids (saline), allowing more time for successful completion of an EMR. Hetastarch, a colloid widely used for volume expansion, is cheap, and is free from transmission of infection (unlike another colloid – albumen). Hetastarch may be used as an alternative to saline injection for EMR. The aim of this report is to compare the duration of submucosal cushion effect of hetastarch injection with saline injection in a live animal model. Methods: Three pigs (weight 85 to 100 lbs) were used for the study. Under general anesthesia, esophageal submucosal injections were done with a 23– gauge needle using a 10 cc syringe, at 5 cm intervals, starting from the gastroesophageal junction. At each site, 2 cc submucosal injections were given using either normal saline or 6% hetastarch. Each injection was observed for 15 minutes. Resolution of submucosal cushion was recorded at 5, 10, 15 minutes following injection. A total 16 injections (n⫽8 saline; n⫽8 hetastarch) were made and studied. Results: Submucosal cushion effect lasted longer with the hetastarch compared with the saline (9.25 ⫹ 2.05 versus 5.75 ⫹ 0.88 minutes, p⫽0.0014). Conclusions: Hetastarch may be an alternative to saline injection, especially in situations where a longer lasting submucosal cushion effect is desired for endoscopic mucosal resection.
Abstracts
S289
880 LONG TERM FOLLOW–UP OF ESOPHAGEAL FOOD IMPACTIONS: THE TRUTH IS NOT THAT HARD TO SWALLOW Robert E. Sedlack, M.D. and Todd H. Baron, M.D.*. Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN. Purpose: Esophageal food impaction often occurs without an identifiable cause. There are no longitudinal data examining heath care utilization or recurrence of symptoms following a single episode of food impaction where no structural abnormalities are identified. This retrospective study sought to determine if pts. with an index episode of food impaction and endoscopically normal esophagus experienced subsequent events or symptoms over the ensuing 5 years. Methods: We reviewed records of pts. with acute food impaction at the Mayo medical center between ‘90 –’96; pts. with first impaction episode and otherwise normal esophagoscopy were identified. Subsequent 5–year rx. and sx. data were obtained by record review and questionnaires. Results: Between ‘90 –’96, 406 pts. with acute esophageal food impaction were identified. In 69 pts., this represented the index episode with no identifiable cause endoscopically. Follow– up data available on 49 (71%) of these pts. form the basis of our cohort. The mean follow– up interval after the index event was 86.4 months (range 1–137). Further testing in 39 (80%) subjects identified a potential cause for impaction in 20 (51%). 34/49 pts. (69%) had only the index event; 24 of these pts. underwent further evaluation revealing a potential source in 10 (42%). Recurrent impaction occurred in 15/49 pts. (31%) with a potential cause discovered in 10 (67%). Impaction recurrence occurred at a mean of 24 months (range 2–74) after the index episode. 28 (41%) pts. returned symptom questionnaires; 14 pts. (50%) had continued dysphagia. Conclusions: 1) 1/3 of pts. with endoscopically normal esophagus at initial food impaction will have a repeat impaction at a mean of 2 years. 2) Further testing will identify a potential cause in 42% of pts. following one episode of food impaction. This yield increases to 2/3 following recurrent impactions. 3) In pts. who present with a food impaction, a potential source may be identified with extensive testing, but the diagnostic yield increases following subsequent food impactions.
881 APPROPRIATENESS OF GENERAL PRACTITIONER’S INDICATIONS FOR DIAGNOSTIC UPPER GASTROINTESTINAL ENDOSCOPY Antonio L. Sanchez–Rio, M.D.*, Enrique Quintero, M.D., Onofre Alarcon, M.D., Salvador Baudet, M.D. and Benjamin Martin, M.D. Digestive Diseases, Hospiten Rambla, Tenerife Island, Santa Cruz de Tenerife, Spain; Digestive Diseases, University Hospital of the Canary Islands, La Laguna, Santa Cruz de Tenerife, Spain and Phamily Medicine, Hospiten Bellevue, Puerto de la Cruz, Santa Cruz de Tenerife, Spain. Purpose: This estudy was aimed at comparing the appropriateness of use of upper gastrointestinal endoscopy (UGE) referred from general practitioners (GP) with those referred from specialists in gastroenterology (SG). Methods: Procedural indications for 162 UGE referred from GP and 136 from SG were systematically and prospectively collected with special attention to disease presentation, previuos tests and treatments. To evaluate the appropriateness we used the American Society for Gastrointestinal Endoscopy criteria for the appropriate use of gastrointestinal endoscopy (ASGE97) and the criteria of the European panel of experts (EPAGE). The ASGE 97 criteria classified the indications in appropriate or inappropriate ones. With the EPAGE criteria we obtained two Results: an ordinal scale from one to nine and a qualitative classification of appropriateness based on this scale (1–3: inappropriate, 4 – 6: uncertain, 7–9: appropriate). Results: Percentage of inappropriate indications based in ASGE 97 criteria were 17.2 for GP and 17.6 for SG (p⫽ 0.29). Based on EPAGE criteria these percentages were 11.8 and 11.4 (p⫽ 0.84). There was no statistical
Abstracts
rable age with liver cirrhoses and bleeding varices subjected to endoscopic variceal sclerotherapy as a control. 3–On the second day after ligation or sclerotherapy both groups subjected to Doppler study using device of 3.5 Mhz (Hetachi 415) and measurement of portal vein haemodynamic parameters (cross sectional area and velocity). 4 – Congestion index was calculated as follow: Cross sectional area divided by Velocity (cm/second) Results: By comparing portal vein haemodynamic parameters in both groups together, endoscopic variceal ligation showed: 1–Insignificant increase in the portal vein cross sectional area mean⫾SD 0.98⫾0.1 (cm2) versus 0.95⫾0.20 respectively P⫽0.6978 2–Insignificant decrease in the portal vein velocity mean⫾SD 10.5⫾1.5 versus 11.1⫾1.9 (cm/sec) respectively P⫽0.478 3–Significant increase in congestion index (cm/sec) mean⫾SD 0.11⫾0.02 versus 0.09⫾0.01 respectively P⫽0.0277 Conclusions: Endoscopic variceal ligation leads to significant increase in the portal vein congestion index more rapidly than sclerotherapy so I recommend the use of drugs that reduce portal pressure before and after the ligation setting, further study including large number of cases may be needed.
876 THE IMPACT OF SEDATION VS. NO SEDATION IN THE PERFORMANCE OF SUCCESSFUL GASTROSCOPY AMONG ANXIOUS PATIENTS: A DOUBLE BLIND PROSPECTIVE RCT Neena S. Abraham, M.D.*, Kara Thompson, M.Sc., Daniel Woo, M.D., Carlo Fallone, M.D., Serge Mayrand, M.D. and Alan N. Barkun, M.D. Division of Gastroenterology & Department of Medicine, Queen Elizabeth II Health Science Centre–Dalhousie University, Halifax, Nova Scotia, Canada and Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada. Purpose: The current literature suggests that parenteral sedation is required to ensure a successful gastroscopy among those patients who exhibit clinically significant pre–procedural anxiety. Yet, no studies have formally studied this subset of patients in a blinded placebo controlled trial. Methods: A prospective randomized controlled double blind trial assigned patients to undergo gastroscopy with the use of standard parenteral sedation vs. placebo. The primary outcome was “successful endoscopy”–– a composite score of the physician’s rating of technical adequacy (1⫽totally inadequate to 4⫽ totally adequate) and the patient’s satisfaction with their level of comfort (1⫽acceptable to 5⫽unacceptable). A planned secondary outcome was the subgroup analysis of those patients with a clinically relevant mood disorder when screened using a validated instrument, the Hospital Anxiety and Depression Scale (HADS). Possible confounders were considered including demographics (age, gender, race, education), prior experience with gastroscopy, expectations and procedural indication. Univariate and multivariate analysis were completed. Results: 420 patients were randomized (N⫽210 active vs. N⫽210 placebo). Groups were similar for all baseline characteristics. The mean age was 54.5 yrs (SD: 16.1), 52% were female, and 63% of gastroscopies performed were “successful”. 45%of patients described themselves as anxious, however, only 13% had evidence of anxiety when screened by HADS. Among those patients with anxiety, successful endoscopy was five times greater when sedated (95% CI: 1.4 –18.7). Among those without anxiety, successful endoscopy was 8.5 times greater when sedated (95%CI: 5.1–14.2). In both univariate and multivariate analysis, the existence of an anxiety disorder did not exert a differential effect on the occurrence of a successful endoscopy, regardless of randomization group. The best predictor of a successful endoscopy, among all patients, was randomization to sedation (OR⫽8.5; 95%CI: 5.1–14.2). Conclusions: The presence of significant pre–procedural anxiety should not be the rationale to sedate a patient prior to diagnostic gastroscopy. The use of sedation improves the odds of a successful endoscopy among all patients.
AJG – Vol. 97, No. 9, Suppl., 2002
877 ENDOSCOPIC PYLORIC BALLOON DILATATION IN PEDIATRIC PATIENTS WITH DELAYED GASTRIC EMPTYING Nick Ogunmola, M.D.,D.C.H.(UK), Marsha Kay, M.D.*, Robert Wyllie, M.D.,FACG and Vera Hupertz, M.D. Pediatric Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH. Purpose: To determine the outcome of endoscopic pyloric balloon dilatation in pediatric patients with delayed gastric emptying at our institution. We sought to determine the rate of success of the procedure and if there were patient characteristics or technical aspects of the procedure that influenced the procedure outcome. Methods: We performed a retrospective chart review of 18 pediatric patients who underwent endoscopic pyloric balloon dilatation at our institution between January 2000 – May 2002. Serial balloon dilation was performed across the pylorus with controlled radial diameter through the scope (TTS) balloons under direct endoscopic visualization.We reviewed each patients symptoms and physical findings, results of gastric emptying tests, serologic evidence of recent viral illnesses, biopsy findings at the time of endoscopy, number of dilatation procedures, technique of dilatation and outcome following the procedure including repeat gastric emptying studies if available. Results: There were 8 boys and 10 girls with a mean age of 13.7 years. The patients were followed up for a mean of 17 weeks. The mean duration of symptoms prior to the first balloon dilation was 23.9 months. 17% had viral syndromes or serology suggestive of a viral illness prior to onset of their symptoms. The indications for the procedure were delayed gastric emptying due to idiopathic causes (33%), Crohns disease (6%), cyclical vomiting (6%), and GERD (55%). 15 of 18 patients had a gastric emptying test prior to the procedure. 93% of patients had an abnormal gastric emptying time for liquids or solids. 39% of patients had more than one dilatation procedure. The mean number of dilatation procedures per patient was 1.5, with a mean inflation pressure of 59 psi. The mean duration of each inflation was 87.6 sec and the mean number of inflations at each procedure was 3.2. Follow– up was available for 15 patients. No complications were seen in any patients. Resolution of symptoms was seen in 27% and improvement of symptoms was seen in an additional 53% of patients. Conclusions: Endoscopic pyloric balloon dilation with TTS balloons is a safe, minimally invasive procedure with an excellent outcome in pediatric patients with many different types of gastric outlet obstruction.This technique may be especially well suited to children who develop a transient post viral gastroparesis with severe symptoms as an alternative to pyloromyotomy. 878 PLACEMENT OF NASOJEJUNAL FEEDING TUBES: AN ALTERNATE TECHNIQUE J. David Bohler, M.D., Mark Delegge, M.D.* and John Fang, M.D. Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC and University of Utah, UT. Purpose: The use of nasojejunal tube for short–term nutritional support is well established. Proper placement of the NJ tube beyond the Ligament of Treitz can be cumbersome secondary to technical difficulties. This results in many endoscopists avoiding the procedure. We offer an alternate technique that is safe and effective. Methods: A retrospective review of 25 patients with nasojejunal feeding tubes placed with the “push technique” was performed from 1/00 to 12/01. This technique is described as follows: first perform upper endoscopy, taking a 12–french nasoenteric tube and placing a 0.52 and 0.35 guidewire inside the tube, but not to the end, to stiffen the tube. Advance the tube with the guidewires through the nare into the stomach. Observe the tube with the endoscope as it is pushed forward by the nurse or assistant through the pylorus into the distal duodenum or jejunum. If the tube tip engages a mucosal fold, a forcep passed through the biopsy channel is used to reposition the tip for advancement.
AJG – September, Suppl., 2002
Results: 25 cases were selected for analysis. 14 were females, mean age was 52.8 years (range 25–78 years). These tubes were used for feeding a mean time of 10.8 days (range 0 –51 days). The procedure time for tube placement was a mean of 13 minutes (range 3–31 minutes) and success was 100% with no associated complications. One patient (4%) developed an occlusion secondary to kinking which was repositioned and used. Five patients (20%) were discharged to home with tubes in place and being used for nutritional support. Nasoenteric tube use was discontinued secondary to resolution of primary indication in 6 (24%), patient intolerance or accidental displacement in 6 (24%), more permanent access (PEG, PEG/J, or PEJ) in 7 (28%), death from primary disease process in 1 (4%) and unknown in 5 (20%). Conclusions: The new push technique for placement of nasojejunal feeding tubes is safe, reproducible, and effective for short–term nutritional support in those patients unable to tolerate gastric enteral nutrition.
879 HETASTARCH AS AN ALTERNATIVE TO SALINE INJECTION FOR ENDOSCOPIC MUCOSAL RESECTION Tony E. Yusuf, M.D., Ijaz Ahmed, M.B.B.S., Doug Brining, D.V.M. and Gottumukkala S. Raju, M.D., FACG*. Internal Medicine, University of Texas Medical Branch, Galveston, TX. Purpose: Submucosal saline injection is widely used to prevent perforation during endoscopic mucosal resection (EMR). However, quick dissipation of saline not only makes EMR difficult, but also increase the risk of perforation from entrapment of muscle in the snare after the loss of submucosal cushion effect. Submucosal cushion effect from a colloid may last longer as colloids tend to get reabsorped slowly compared to crystalloids (saline), allowing more time for successful completion of an EMR. Hetastarch, a colloid widely used for volume expansion, is cheap, and is free from transmission of infection (unlike another colloid – albumen). Hetastarch may be used as an alternative to saline injection for EMR. The aim of this report is to compare the duration of submucosal cushion effect of hetastarch injection with saline injection in a live animal model. Methods: Three pigs (weight 85 to 100 lbs) were used for the study. Under general anesthesia, esophageal submucosal injections were done with a 23– gauge needle using a 10 cc syringe, at 5 cm intervals, starting from the gastroesophageal junction. At each site, 2 cc submucosal injections were given using either normal saline or 6% hetastarch. Each injection was observed for 15 minutes. Resolution of submucosal cushion was recorded at 5, 10, 15 minutes following injection. A total 16 injections (n⫽8 saline; n⫽8 hetastarch) were made and studied. Results: Submucosal cushion effect lasted longer with the hetastarch compared with the saline (9.25 ⫹ 2.05 versus 5.75 ⫹ 0.88 minutes, p⫽0.0014). Conclusions: Hetastarch may be an alternative to saline injection, especially in situations where a longer lasting submucosal cushion effect is desired for endoscopic mucosal resection.
Abstracts
S289
880 LONG TERM FOLLOW–UP OF ESOPHAGEAL FOOD IMPACTIONS: THE TRUTH IS NOT THAT HARD TO SWALLOW Robert E. Sedlack, M.D. and Todd H. Baron, M.D.*. Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN. Purpose: Esophageal food impaction often occurs without an identifiable cause. There are no longitudinal data examining heath care utilization or recurrence of symptoms following a single episode of food impaction where no structural abnormalities are identified. This retrospective study sought to determine if pts. with an index episode of food impaction and endoscopically normal esophagus experienced subsequent events or symptoms over the ensuing 5 years. Methods: We reviewed records of pts. with acute food impaction at the Mayo medical center between ‘90 –’96; pts. with first impaction episode and otherwise normal esophagoscopy were identified. Subsequent 5–year rx. and sx. data were obtained by record review and questionnaires. Results: Between ‘90 –’96, 406 pts. with acute esophageal food impaction were identified. In 69 pts., this represented the index episode with no identifiable cause endoscopically. Follow– up data available on 49 (71%) of these pts. form the basis of our cohort. The mean follow– up interval after the index event was 86.4 months (range 1–137). Further testing in 39 (80%) subjects identified a potential cause for impaction in 20 (51%). 34/49 pts. (69%) had only the index event; 24 of these pts. underwent further evaluation revealing a potential source in 10 (42%). Recurrent impaction occurred in 15/49 pts. (31%) with a potential cause discovered in 10 (67%). Impaction recurrence occurred at a mean of 24 months (range 2–74) after the index episode. 28 (41%) pts. returned symptom questionnaires; 14 pts. (50%) had continued dysphagia. Conclusions: 1) 1/3 of pts. with endoscopically normal esophagus at initial food impaction will have a repeat impaction at a mean of 2 years. 2) Further testing will identify a potential cause in 42% of pts. following one episode of food impaction. This yield increases to 2/3 following recurrent impactions. 3) In pts. who present with a food impaction, a potential source may be identified with extensive testing, but the diagnostic yield increases following subsequent food impactions.
881 APPROPRIATENESS OF GENERAL PRACTITIONER’S INDICATIONS FOR DIAGNOSTIC UPPER GASTROINTESTINAL ENDOSCOPY Antonio L. Sanchez–Rio, M.D.*, Enrique Quintero, M.D., Onofre Alarcon, M.D., Salvador Baudet, M.D. and Benjamin Martin, M.D. Digestive Diseases, Hospiten Rambla, Tenerife Island, Santa Cruz de Tenerife, Spain; Digestive Diseases, University Hospital of the Canary Islands, La Laguna, Santa Cruz de Tenerife, Spain and Phamily Medicine, Hospiten Bellevue, Puerto de la Cruz, Santa Cruz de Tenerife, Spain. Purpose: This estudy was aimed at comparing the appropriateness of use of upper gastrointestinal endoscopy (UGE) referred from general practitioners (GP) with those referred from specialists in gastroenterology (SG). Methods: Procedural indications for 162 UGE referred from GP and 136 from SG were systematically and prospectively collected with special attention to disease presentation, previuos tests and treatments. To evaluate the appropriateness we used the American Society for Gastrointestinal Endoscopy criteria for the appropriate use of gastrointestinal endoscopy (ASGE97) and the criteria of the European panel of experts (EPAGE). The ASGE 97 criteria classified the indications in appropriate or inappropriate ones. With the EPAGE criteria we obtained two Results: an ordinal scale from one to nine and a qualitative classification of appropriateness based on this scale (1–3: inappropriate, 4 – 6: uncertain, 7–9: appropriate). Results: Percentage of inappropriate indications based in ASGE 97 criteria were 17.2 for GP and 17.6 for SG (p⫽ 0.29). Based on EPAGE criteria these percentages were 11.8 and 11.4 (p⫽ 0.84). There was no statistical